EX  UBRTS  ^ 

INWARD   J.  ILL 


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OVARIAN  AND  UTERINE  TUMOURS 


Digitized  by  the  Internet  Archive 

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ON 


OVARIAN  AND  UTERINE  TUMOURS 


THE  IE    DIAGNOSIS   AND    TREATMENT 


BY 


T.  SPENCER  WELLS 


VICE-PRESIDENT     OP     THE    ROYAL     COLLEGE     OF    SURGEONS    OP    ENGLAND 

HONORARY  M.D.  OP  THE  UNIVERSITIES  OP  LEYDEN  AND  CHARKOFF 

HONORARY  FELLOW  OF  THE  KING  AND   QUEEN'S  COLLEGE  OF  PHYSICIANS  IN  IRELAND 

SURGEON  IN  ORDINARY  TO  THE  QUEEN'S  HOUSEHOLD 

CONSULTING  SURGEON  TO  THE  SAMARITAN  HOSPITAL  FOR  WOMEN 

MEMBER  OP  THE  IMPERIAL  SOCIETY  OP  SURGERY  OP  PARIS,  OP  THE  MEDICAL  SOCIETY 

OP  PARIS,  AND  OP  THE  MEDICAL  SOCIETY  OF  SWEDEN 

HONORARY  MEMBER  OF  THE  ROYAL  ACADEMY  OP  MEDICINE  OF  BELGIUM,  OF  THE  ROYAL  SOCIETY  OF 

MEDICAL  AND  NATURAL  SCIENCE  OP  BRUSSELS  AND  OF  THE  MEDICAL  SOCIETD3S  OP  PESTH 

AND    OF    HELSINGFORS,    OF    THE    ROYAL    SOCIETY   OF    SCIENCES   AND    ARTS    OF 

GOTHENBURG,    AND  OF  THE  PHYSICO-MEDICAL  SOCIETY  OF  MOSCOW 

HONORARY  FELLOW  OF  THE  AMERICAN  GYNECOLOGICAL  SOCIETY,  OF  THE  OBSTETRICAL 

SOCIETIES  OF  BERLIN,  OP  LEIPZIG,  AND  OF  DRESDEN 


PHILADELPHIA 
P.    BLAKISTON,     SON,     AND    CO. 

1012    WALNUT    STREET 

1882 


ibudutcJ) 


Hi*' 


PBEFACE 


It  is  now  twenty-four  years  since  I  first  attempted 
Ovariotomy.  During  this  time  I  have  offered  to  my 
professional  brethren  no  less  than  three  books  upon 
the  subject,  each  of  them  marking  a  stage  in  the 
progress  of  the  operation. 

The  first  book  was  published  in  1864,  when  every- 
thing was  tentative,  facts  were  accumulating,  and  the 
bases  of  the  rules  of  future  action  were  being  laid  down. 
It  was  rather  the  fulfilment  of  a  pledge  to  record  all 
that  I  did,  so  as  to  furnish  the  means  of  judging  how 
far  my  proceedings  were  justified,  than  a  guide  for 
other  practitioners.  It  contained  many  useful  lessons, 
and  opened  up  for  discussion  almost  all  the  important 
practical  questions. 

My  second  book,  which  appeared  in  1872,  was  the 
result  of'  much  larger  experience,  and  gave  me  the 
opportunity  of  speaking  with  more  authority  on  points 
which  I  had  been  able  to  study,  and  of  laying  before 
the  profession  the  views  and  mode  of  practice  which  I 
had  then  adopted.  The  weight  of  its  evidence  definitely 
settled  all  doubts  as  to  the  utility  of  Ovariotomy,  and 
stimulated  into  activity  many  coadjutors.  Ovariotomy 
is  no  longer  an  isolated  part  of  surgery.     The  last  ten 


VI  PREFACE 


years'  practice  in  abdominal  surgery  have  thrown  open 
a  much  wider  field  of  observation  and  yielded  a  fund  of 
invaluable  record.  And  this  I  have  ranged  over  and 
sifted  sedulously  in  search  of  instruction,  adjusting  to 
my  various  exigencies  every  suggestion  which  I  con- 
sidered, or  which  promised,  to  be  an  improvement.  I 
thankfully  acknowledge  a  great  gain  of  knowledge, 
which  has  led  to  some  changes  of  opinion  and  to  some 
modification  of  my  operative  work. 

The  book  which  I  now  issue  is  professedly  a  second 
edition  of  that  of  1872,  but  so  far  as  the  operation  of 
Ovariotomy  is  concerned  it  is  almost  new,  and  as  regards 
the  uterine  section  still  more  so.  There  will  be  found  in 
it  the  most  recent  information  I  have  been  able  to 
collect  and  the  results  of  my  latest  efforts.  It  is  satis- 
factory to  find  that  everywhere  there  are  proofs  of  the 
extension  of  our  beneficent  work  and  of  increasino- 
success.  Yet  I  am  still  a  student  among  many  fellow 
workers,  and  await  the  fruits  of  further  research.  For 
however  much  we  may  congratulate  ourselves  upon 
what  has  been  done  in  the  way  of  operation  to  save 
those  who  demanded  help  in  the  last  extremity,  the 
scientific  aspect  of  the  subject  of  ovarian  and  uterine 
tumours  leads  us  to  look  for  the  restriction  of  the  area 
for  the  application  of  our  surgical  measures,  and  to 
hope  that  the  pathological  industry  of  those  who  are  not 
overwhelmed  with  the  routine  of  mere  clinical  labour 
will  bring  us  to  such  an  understanding  of  the  origin, 
causes,  and  nature  of  these  diseases  as  will  give  us  the 
means  of  arresting  their  development  and  progress,  and 
will  shield  us  from  the  reproach  of  being  able  only  to 
offer  the  ultimate  resource  of  relief  by  excision. 


7hZI±.Z  ■.-;: 

Id  the  arrangement  of  the  matters  of  which  I  had  to 
write  into  chapters  I  have  so  strictly  followed  the 
natural  divisions  of  the  subject,  that  a  reader  wishing  to 
inform  himself  on  any  particular  question  will  be  led  to 
it  at  once  by  the  table  of  contents ;  and  I  have  preferred 
using  this  form  of  clue  to  that  of  an  alphabetical  index 
on  account  of  its  simplicity  and  directness  The  line  of 
demonstration  and  of  argument  can  be  traced  at  a 
glance,  and  the  place  of  every  record  of  fact,  or  reference 
to  authority,  is  exactly  indicated  by  name  and  page. 

Tip  to  May  1, 1882,  my  completed  cases  of  Ovari- 
otomy amount  to  1071,  and  of  the  seventy-^me  follow- 
ing the  one  thousand  upon  which  all  the  calculations 
in  the  text  are  founded  only  four  have  died,  while  sixty- 
seven  have  recovered ;  a  further  proof,  if  any  were 
wanted,  that  notwithstanding  the  fact  of  my  being  often 
called  upon  to  treat  patients  rejected  by  other  surgeons 
as  unfavourable  cases,  the  progressive  diminution  of  the 
mortality  still  continues.  It  is  still  more  gratifying  to 
be  able  to  add  that  this  increasing  success  is  not  con- 
fined to  myself  or  to  British  surgeons,  but  is  also  estab- 
lished in  Germany,  France,  and  Italy.  In  addition  to 
the  facts  summarised  in  the  fifth  Chapter,  I  have  great 
pleasure  in  adding,  at  the  last  moment,  that  my  friend 
Professor  Schroder,  of  Berlin,  who  in  his  first  hundred 
cases  lost  seventeen,  and  in  his  second  eighteen,  has 
only  lost  seven  in  his  third  series  of  one  hundred  cases 
just  completed. 

Upfee  Gbostesob  Sikeet  : 
May  1T  1882 


CONTENTS 


INTRODUCTION 

THE   REPRODUCTIVE  CELL— OVUM  AND   OVARY. 

influence  of  the  ovaries  in  health  and  disease,  page  1. 
interest  of  ovarian  pathology,  1. 
periodicity  of  female  life,  2. 

successive  changes  in  ovarian  structure  and  function,  2. 
phenomena  of  ovulation,  3. 
Graafian  vesicles,  3. 
corpora  lutea,  3. 
ovarian  anomalies,  4. 
displacements  of  the  ovaries,  4. 
modes  of  examination,  5-6. 

hyperemia  and  inflammation  of  the  ovary  often  the  origin  of  cystic 
tumours,  7. 

CHAPTER   I. 

THE   DIFFERENT   KINDS   OF   OVARIAN   TUMOURS. 

Ovarian  Tumours  of  three  kinds  ;  their  Morphological  Classification : 

1.  Adenoid  Tumours. 

a.  hypertrophy  of  part  or  whole  of  the  gland. 

b.  simple  cysts — enlarged  Graafian  follicles. 

c.  multiple  cysts — cysts  in  apposition  forming  multilocular  tu- 

mours. 

d.  proliferous  cysts— parent  cysts  with  secondary  cysts  growing 

from  the  interior  of  cyst  wall. 

2.  fibrous — growth  of  stroma  of  ovary. 

3.  malignant  and  tubercular — cancer,  tubercle,  8. 

Extra-  Ovarian  Tumours, 

cysts  of  Fallopian  tube  and  terminal  vesicle 

cysts  of  broad  ligament  or  vesicles  of  Wolffian  body. 

cysts  developed  from  tubules  of  parovarium. 

cysts  developed  in  the  sub-peritoneal  tissue  of  the  pelvis  and  abdomen. 

cysts  developed  from  ova  attached  to  the  peritoneal  surface,  8-9. 


CONTENTS 


Descriptive  Classification. 
Simple  Cysts. 

1.  ovarian — enlarged  Graafian  follicles. 

2.  extra-ovarian. 

a.  cysts  of  Wolffian  body. 

o.  cysts  of  broad  ligament. 

c.  cysts  of  Fallopian  tube. 

d.  cysts  developed  in  the  sub-peritoneal  tissue  of  the  pelvis  or 

abdomen. 

e.  cysts  developed  from  aberrant  ova. 

Compound,  Adenoid  Tumours. 

1.  multiple — cysts  aggregated  together. 

2.  proliferous — parent  cysts,  filled  with  cysts  of  secondary  growth. 

Fibrous,  Malignant,  and  Tubercular  Tumours,  9. 
Simple  Ovarian  Cysts. 

description  and  general  characteristics,  9. 

structure  of  cyst  walls,  histological  elements,  vascular  condition,  origin 

of  cysts  from  diseased  vessels,  10. 
nerves  and  lymphatics,  relation  of  Fallopian  tube  to  cyst,  origin  of 

simple  cysts,  the  ovum  in  simple  cysts,  morbid  enlargement  often 

the  result  of  follicular  haemorrhage,  11. 
cysts  from  corpus  luteum,  description  of  by  Eokitansky,  hyperasmia 

cause  of  cystic   degeneration,   opinions  of    Scanzoni,   Klob,   and 

Schultze,  12. 
Views  of  Grohe,  effects  of  congestion  and  local  inflammation,  13. 

Simple  Extra-  Ovarian  Cysts. 

on  the  broad  ligament,  ordinary  conditions  of,  14. 
illustrative  case,  cysts  described  by  Huguier,  15. 

cysts  developed  from  ova  attached  to  the  peritoneum,  suggestions  by 
Boinet  and  Ritchie,  16. 

Tubo-  Ovarian  Cysts. 

described  by  Richard  and  Labbe,  mode  of  origin,  17. 
cases  by  author  and  Dr.  Beale,  18. 

Multiple  Ovarian  Cysts. 

begin  by  the  coincident  enlargemen   of  several  Graafian  follicles,  19. 
their  growth  and  structural  changes,  20. 
other  modes  of  origin  in  the  stroma  of  ovary,  21. 

Leopold,  of  Leipsig,  and  Cohnheim  on  the  persistence  and  transplanta- 
tion of  embryonic  tissues,  22. 

Proliferous  Cysts. 

description  and  mode  of  origin,  23. 

secondary  cysts  developed  from  epithelium  of   (he  parent  cjTSt,  epi- 
thelial transformations,  24. 


CONTENTS  xi 

» 

secondary  cysts  from  Graafian  follicles  in  cyst  walls,  ova  observed  in 
them  by  Rokitansky  and  Ritchie,  25. 

Ritchie  on  the  formation  of  cysts  from  follicles  and  ova,  26. 

Ritchie  on  the  presence  of  ova  in  the  loculi  of  ovarian  cysts,  27. 

Wilson  Fox  on  the  origin  of  ovarian  cysts,  28. 

case  described  by  author  as  a  enoma,  29. 

Fox  on  epithelial  and  colloid  growths,  30-31. 

Harris  and  Doran  on  the  earlier  stages  of  cystic  disease,  32-34. 
Dermoid  Cysts. 

another  form  of  proliferous  cyst  with  higher  development,  new  form- 
ations and  arrest  of  growth,  discharge  of  contents,  muscular  fibre 
observed  by  Virchow,  35. 

other  tissues  reported  by  various  authors,  case  by  Friedreichs,  36. 

not  exclusively  ovarian,  found  in  males,  37. 

description  of  dermoid  tumours  and  their  contents,  38. 

not  the  result  of  impregnation,  doctrine  of  continuous  development,  39. 

extra-uterine  fcetation,  no  analogy  with  dermoid  tumours, '  monstrosities 
by  inclusion,'  duration  of  dermoid  tumours,  40. 

formative  power  in  ovarian  cysts,  41. 

cases  operated  on  by  author,  42-43. 

Cystosarcoma. 

description  of,  hyperplastic  condition  of  cell  walls,  44. 
cases  of,  45-47. 

Fibrous  Tumours  of  Ovary. 

of  rare  occurrence,  two  cases  reported  by  Kiswich,  47. 

the  author's  experience  confined  to  three  cases,  in  one  of  which  both 

ovaries  were  in  the  same  condition,  48. 
case  presented  to  the  Obstetrical  Society,  48. 

Cancer  of  the  Ovary. 

no  special  form  of  cancer  in  the  ovary,  its  structure  and  constituent 
tissues  prefigure  the  various  types  of  disease,  49. 

Paget  on  hard  cancer  of  the  ovary,  49. 

tendency  of  cystic  tumours  to  degenerate  into  the  colloid  form,  an 
intermediate  condition  between  simple  cyst  and  malignant  growth, 
description,  mode  of  growth,  alveoli  and  contents,  50. 

case  illustrating  the  progress  of  the  disease,  report  of  post-mortem  by 
Mr.  Jardine,  51. 

dendritic  growths  in  cysts  degenerate  into  epithelioma  and  medullary 
cancer,  51. 

cancer  sometimes  primary  affection  of  the  ovary,  without  cyst  form- 
ation, 53. 

cancer  of  both  ovaries,  54. 

cancer  of  one  ovary,  with  cystic  disease  of  the  other,  55. 

cancer  involving  both  ovaries  in  a  child,  account  of  case  and  post- 
mortem, 56-58. 

Tubercle  of  the  Ovary. 

Rokitansky  denied  the  fact  of  its  occurrence,  58. 
report  by  Wilson  Fox  on  cyst  removed  by  author,  58. 
author  has  seen  several  other  cases,  59. 


11  CONTENTS 

The  Pedicle. 

structure  of,  59. 

peculiarities  of,  60. 

rotation  of  tumours  first  described  by  Rokitansky,  61. 

direction,  extent,  and  consequences  of  twisting  of  the  pedicle,  62. 

constriction  of  vessels,  haemorrhage  and  rupture  of  the  cyst,  atrophy 
and  subsidence  of  the  tumour,  division  of  the  pedicle,  transplan- 
tation of  tumour,  and  nutrition  through  vessels  of  adhesions,  62. 

two  cases  of  removal  of  such  self-grafted  tumours,  62-63. 

death  from  haemorrhage  into  a  rotated  cyst,  63. 

recovery  after  cystic  haemorrhage  from  rotation,  64. 

sessile  tumours  without  pedicle,  enucleation  of,  65. 

Degeneration  of  Cyst  Walls. 

liability  of  ovarian  cysts  to  inflammation,  formation  of  adhesions  and 

pus,  contents  sometimes  find  their  way  into  other  organs,  septic 

and  pyaemic  fever,  65. 
perforation  and  passage  of  fluids  into  the  peritoneal  cavity,  no  bar  to 

operation,  66. 
case  illustrating  this  point  of  practice,  67. 
anaemic  condition  of  the  tissues,  fatty  degeneration,  68-69. 
chalky  deposit  in  cyst  walls,  70. 

CHAPTER   II. 

DIAGNOSIS   AND   DIFFERENTIAL    DIAGNOSIS. 

many  of  the  signs  and  symptoms  common  to  the  whole  group,  physical 
signs  in  connection  with  the  nature  of  the  contents,  evidence  of 
symptoms  more  circumstantial  than  specific,  71. 

age  of  patients,  side  of  disease,  duration,  72. 

Diagnosis  of  the  Different  Kinds  of  Ovarian  Tumours  and  their  Adliesions. 
diagnosis  of  solid  tumours,  73. 
diagnosis  of  simple  cysts,  74. 
diagnosis  of  multilocular  cysts,  75. 

A  illusions. 

adhesions  to  abdominal  wall  do  not  much  affect  the  general  results  of 
ovariotomy,  76. 

position  of  patient  for  examination,  evidence  from  respiratory  move- 
ments and  sounds  on  percussion,  77. 

crepitus  and  friction  sounds,  difference  between  those  produced  by 
omentum  and  adliesions,  78. 

pelvic  adhesions  of  more  importance,  79. 

Differential  Diagnosis  of  Ovarian  Tumours. 

enumeration  of  the  principal  states  and  diseases  which  may  throw 
doubt  on  the  diagnosis,  80-81. 

mechanical  interference  of  tumours  with   the  action  of  thoracic  ab- 
dominal, and  pelvic  organs,  81. 
:  .'ii  physiognomy,  82. 


CONTENTS  Xlll 

local  effects  of  ovarian  tumours,  83. 

thoracic  alterations  often  impeding  recovery  after  tapping  and  ovari- 
otomy, 84. 

Diagnosis  between  Ovarian  Dropsy  and  Ascites. 

inspection — form,  appearance  of  superficial  veins,  varicose  lymphatics, 
movements  during  respiration,  85-86. 

measurement — circular  at  level  of  umbilicus,  radiating  from  umbilicus 
to  sternum,  pubes,  and  crest  of  ilium,  87. 

palpation — showing  resistance  of  abdominal  wall,  variations  of  fluctu- 
ation and  distension,  87. 

percussion  and  auscultation — practical  remarks  on  the  evidence  of 
fluctuation,  88-89. 

auscultation  alone  affords  little  information,  89. 

chemical  and  microscopical  examination  of  ovarian  fluids,  90. 

composition  and  chemical  constituents  of  ovarian  fluids,  91-  94, 

recent  investigations  by  Dr.  C.  Mehu,  95-96. 

microscopical  evidence  uncertain,  96. 

sometimes  useful  in  showing  the  existence  of  malignant  degeneration, 
observations  of  Foulis  and  Thornton,  97-98. 

Diagnosis  of  Encysted  Dropsy  and  Changes  produced  by  Chronic  Inflam- 
mation and  Cancer  of  the  Peritoneum. 

peritoneal  fluid  sometimes  confined  in  pouches,  remarks  by  Dr.  West,  98. 
distinguishing  signs,  99. 
case  of  chronic  peritonitis,  99. 
tubercular  peritonitis,  100. 
case  of  tubercle  and  ascites,  101-102. 
deceptive  symptoms  of  cancer  of  peritoneum,  102. 
case,  with  report  of  examination,  103-104. 

piliferous  cyst  of  ovary  with  malignant  disease  of  abdomen,  105. 
indications  of  malignant  disease  accompanying  ovarian  cysts,  106. 

Tympanites  and  Phantom  Tumours. 

observations  of  Bright  and  Simpson,  106. 

cases  of  hysteric  tympanites,  107-110. 

sometimes  accompanies  uterine  and  ovarian  disease,  and  pregnancy,  110. 

once  seen  by  author  in  a  man,  111. 

Fibro-Plastic  and  Patty  Tumours  of  Peritoneum,  Omentum,  and  Sub-Peri- 
toneal Cellular  Tissue. 
real  nature  only  determined  in  some  cases  by  tapping  or  exploratory 

incision,  111. 
case  of  fatty  tumour  partially  removed,  111. 
case  of  fibro-plastic  tumour,  with  report  by  Wilson  Fox,  112. 
tumour  removed  by  author,  and  described  by  Virchow  as  '  fibroma  mol- 

luscum  cysticum  abdominale,'  113-114. 
myxoma-lipomatodes  recurrent,  115. 

Hydatids. 

their  diagnosis  from  ovarian  tumours,  115. 
eases  of  hydatids  of  peritoneum,  116-117. 
not  found  in  substance  of  the  ovary,  118. 


iv  CONTENTS 

Pregnancy. 

common  cause  of  error  in  diagnosis,  not  important  at  an  early  period, 

119. 
diagnosis  influenced  by  considerations  of  age  of  patient,  condition  of 

the  organs  of  generation,  size  and  position  of  the  swelling,  duration 

of  its  growth,  disturbance  of  functions,  state  of  general  health,  and 

physiognomy,  120. 
symmetry  of  the  abdomen,  condition  of  superficial  veins,  sounds  of  the 

foetal  heart,  121. 
fluctuation,  ballottement,  state  of  the  os  uteri,  122. 
extra-uterine  foetation,  question  often  decided  by  early  death  of  the 

patient,  diagnosis  after  third  or  fourth  month,  123. 
uterine   enlargements  without   pregnancy,  hydatids,  polypus,  cancer, 

hsematometra,  hydometra,  physometra,  124. 
summary  of  signs  of  ovarian  enlargement,  125. 

Renal  Cysts  and  Tumours. 

mistaken  diagnosis  exceptional,  126. 

case  of  soft  cancer  of  the  right  kidney  in  a  child  four  years  old,  127. 

remarks  by  Dr.  Roberts,  of  Manchester,  128. 

position  of  the  tumour  in  renal  cysts,  128. 

absence  of  fluctuation,  129. 

case  of  pyonephrosis,  130-131 . 

peri-renal  abscess,  removal  of  renal  calculus,  132. 

case  of  cystic  degeneration  of  the  kidney  mistaken  for  ovarian  cyst, 

operation,  post-mortem,  and  previous  history,  132-136. 
rupture  of  renal  cyst,  137. 

exploratory  incision  in  a  case  of  renal  cyst,  138. 

exploratory  incision  for  renal  cyst  followed  by  uremic  fever,  139-140. 
summary  of  diagnosis  of  renal  cysts,  141-143. 

Distended  Bladder. 

of  common  occurrence  with  both  uterine  and  ovarian  tumours,  has  been 
mistaken  for  cystic  tumour,  necessity  for  using  a  long  catheter, 
143. 

Fecal  Accumulations. 

remarks  by  Simpson,  144. 

case  of,  resembling  an  ovarian  cyst  requiring  a  modified  Nelaton's 
operation,  145. 

Pelvic  Cellulitis  and  Abscess. 

many  supposed  cases  of  erne  of  ovarian  and  uterine  tumours  really 
pelvic  abscesses,  distinguishing  symptoms,  146. 

Hematocele. 

often  the  cause  of  pelvic  cellulitis  and  abscess,  only  when  large  and 

sudden  that  it  forms  an  abdominal  tumour,  more  frequently  pelvic, 

147. 
more  rapidly  developed  and  attended  by  severer  symptoms  than  ovarian 

cysts,  148. 
case  illustrating  the  course  and  danger  of  the  disease,  148. 
other  diseases  mistaken  for  ovarian  cysts,  149. 


*  CONTENTS  XV 

CHAPTER   III. 

THE   MEDICAL   TREATMENT   OP   OVARIAN   TUMOURS. 

generally  unsatisfactory,  for  the  most  part  palliative,  1 50. 

importance   of   avoiding  pregnancy  and  guarding  against   accidents 

causing  inflammation  or  rupture,  161. 
specific  remedies  have  mostly  proved  useless  and  often  injurious,  case 

of  exceptional  cure  by  purgatives,  152. 
question  of  time  for  surgical  interference,  153. 
enumeration  of  minor  methods  of  surgical  treatment,  154. 

CHAPTER   IV. 

ON   THE  PALLIATIVE  AND  MINOR  SURGICAL   TREATMENT   OF  OVARIAN 

TUMOURS. 

Tapping. 

absolutely  forbidden  by  Stilling,  objected  to  by  many  other  surgeons, 

155. 
erroneous  notions  as  to  the  fatality  of  tapping,  remarks  on  the  danger 

of  the  operation,  1 56. 
may  be  practised  simply  or  with  various  combinations  of  drainage  and 

pressure,  157. 

Tapping  through  the  Abdominal  Wall. 

how  done  formerly  and  the  consequences,  157. 

Simpson's  calculation  that  the  mortality  was  one  in  six,  certainly  not 

one  in  sixty  in  author's  experience,  precautions  to  be  observed,  and 

modifications  in  the  mode  of  operation,  158. 
condition  of  the  cyst  wall  sometimes  the  cause  of  difficulty  from  partial 

thickness  or  bony  deposit,  159. 
improvements  in  the  trocar,  Mr.  Thompson's  trocar,  159. 
description  and  mode  of  use,  160. 
modifications  of  the  syphon  trocar,  161. 

with  syringe,  action  may  be  reversed  for  washing  out  cysts,  162. 
used  instead  of  aspirators,  163. 

bleeding  after  tapping,  and  the  treatment  required,  163-164. 
cases  showing  the  success  of  tapping  in  some  cases  of  single  cysts, 

165-166. 
author's  experience  in  accord  with  the  conclusions  of  Dr.  Mehu,  166. 
influence  of  tapping  on  ovariotomy,  table,  167. 

does  not  affect  the  result  of  the  operation  by  more  than  2  per  cent.,  167. 
practical  conclusions  in  reference  to  tapping,  168. 

Tapping  through  the  Vagina. 

more  dangerous  than  tapping  through  the  abdominal  wall  from  the 
probable  entrance  of  air,  putrefaction,  and  septicemia,  should  be 
an  exceptional  practice,  may  be  necessary  when  a  cyst  is  bound 
a 


XVI  CONTENTS 

down  by  adhesions  in  the  pelvis,  means  of  preventing  the  canula 

from  slipping  out  and  the  wound  closing,  169. 
cases  successful  and  unsuccessful  with  drainage,  170-175. 
simple  tapping   more   hazardous   than   when   followed    by   drainage, 

drainage  should  be  continued  till  the  cavity  is  obliterated,  better 

to  remove  a  cyst,  if  possible,  than  to  trust  to  drainage,  176. 

Tapping  through  the  Rectum.. 

supposed  by  some  to  have  advantages  over  tapping  by  vagina,  no 
practical  proof  of  this,  176. 

Injection  of  Iodine. 

strongly  advocated  by  Boinet,  now  fallen  into  desuetude,  simple  tapping 

quite  as  effectual  in  proper  cases,  177. 
useful  for  washing  out  drainage  cases,  sulphurous  acid  preferable,  177. 

Treatment  by  Incision. 

how  it  probably  originated,  more  dangerous  than  ovariotomy,  how 
practised  by  some  surgeons,  only  admissible  when  ovariotomy 
cannot  be  completed,  178. 

CHAPTEE   V. 

THE   RISE  AKD  PEOGBESS  OP  OVAEIOTOMY. 

derivation  of  the  name,  notices  by  ancient  writers,  179. 

practised  by  the  natives  of  Australia  and  New  Zealand,  proposed  in 

the  17th  century  for  the  treatment  of  nymphomania  and  dropsy  of 

the  ovaries,  180-181. 
only  generally  adopted  as  a  means  of  radical  cure  within  the  last  five- 

and-twenty  years,  181. 
quotations  from  the  writings  of  Dr.  W.  Hunter  and  John  Hunter,  182. 
advocated  by  Chambon  in  1798,  183. 

lectures  on  the  subject  by  John  Bell  attended  by  McDowell,  184. 
McDowell  the  first  successful  ovariotomist,  184. 
reasons  why  it  was  not  earlier  adopted  in  this  country,  185. 
McDowell's  first  operation  in  1809,  186. 
his  character  as  a  surgeon,  187. 
cases  reported  as  ovariotomy,  188. 
ovariotomy  attempted  by  Houston,  1701,  189. 
McDowell's  subsequent  cases,  190. 
cases  by  Smith,  of  Connecticut,  1822,  190. 

Ovariotomy  in  Great  Britain. 

unsuccessful  cases  by  Lizars  and  Granville,  191. 
first  successful  case  by  Jeaffreson,  1836,  191. 
other  cases  by  King,  West,  and  Crisp,  191. 

operation  first  completed  in  London  by  Benjamin  Phillips,  1840,  192. 
Dr.  Clay,  of  Manchester,  began  in  1842,  192. 

first  successful  case  in  London  by  Walnc,  1842,  other  operations  in 
England  to  1846,  192. 


CONTENTS  XV11 

Mr.  Solly's  lecture  on  pedicle,  1846,  192. 

first  successful  ovariotomy  in  a  London  hospital  by  Mr.  Cassar  Hawkins, 

1846,  193. 
other  English  operators  between  1846  and  1850,  193. 
DufEn's  views  on  the  treatment  of  the  pedicle,  his  publication,  effect 

of,  1850,  not  a  mere  imitator  of  Stilling,  193-195. 
Einnahen,  or  '  pocketing  the  pedicle  '  of  Langenbeck  and  Storer,  195. 
the  Samaritan  Hospital,  its  beginning,  my  first  connection  with  it  in 

1854,  my  first  experience  of  ovariotomy  in  1854  with  Baker  Brown, 

and  Nunn,  absence  in  the  Crimea,  1855-56,  195. 
beginning  of  operative  work  at  the  Samaritan  by  Snow  Beck,  196. 
my  first  exploratory  incision  for  ovarian  disease  in  1857,  first  ovariotomy 

in  1858,  196. 
removal  of  the  Samaritan  Hospital,  my  second  and  third  ovariotomies, 

197. 
my  fourth  operation  fatal,  post-mortem  by  Dr.  Aitken,  197. 
led  to  experiments  on  animals,  useful  results  of,  practice  in  1859,  198. 
progress  of  ovariotomy  during  the  next  five  years,  199. 
publication  of  my  first  book  in  1864,  reasons   for  and  account  of, 

199-200. 
questions  under  discussion  at  that  time,  length  of  incision,  200. 
treatment  of  pedicle,  201. 
the  clamp  and  modifications  of,  202-203. 
its  use  in  extra-peritoneal  treatment  of  the  pedicle,  204. 
inducements  to  follow  the  extra-peritoneal  treatment  of  the  pedicle, 

205. 
position  of    the   patient   under  ovariotomy,  my  preference   for  the 

recumbent  position,  operating  tables,  2061. 
closure  of  the  wound,  trial  of  various  methods  leading  to  adoption  of 

sutures,  207-208. 
symptoms  at  that  time  often  misunderstood,  209. 

vague  notions  about  septicaemia,  practical  lessons  from  early  cases,  210. 
origin  of  antiseptics,  211. 
completion  of  five  hundred  cases  in  1872,  publication  of  my  second 

book,  212. 
introduction  of  methylene,  212. 
novelties  in  hospital  practice,  213. 
end  of  my  hospital  work,  1877,  214. 
results  of  hospital  work,  214. 
address  on  leaving  hospital,  215-216. 
practice  of  my  colleagues  in  hospital,  217. 
private  practice  after  leaving  hospital,  218. 
additions  to  my  antiseptic  precautions,  219. 

recent  modifications  in  my  ovariotomy  practice  and  results,  220-221. 
mortality  before  and  after  antiseptics,  222. 
objections  to  Lister's  spray,  223. 
report  of  practice  of  Dr.  Keith,  224. 

Ovariotomy  in  France. 

early  opposition  by  Velpeau,  225. 
advocated  by  Cazeaux  and  Worms,  225. 

a  2 


XVI 11  CONTENTS 

investigations  and  example  of  Nelaton,  225. 
operation  first  undertaken  by  provincial  surgeons,  225. 
practice  of  Koeberle,  report  of  Pean,  226. 

Ovariotomy  in  Belgiwni. 

first  done  by  me  in  Brussels,  1865,  226. 
practice  of  Boddaert  and  Deroubaix,  227. 

Ovariotomy  in  Switzerland. 

first  done  by  me  in  Zurich,  1864,  227. 

report  by  Kocher    on   operations  done   by  himself  and   other  Swiss 
surgeons,  228. 

Ovariotomy  in  Germany. 

begun  by  Chrysmar  and  Dzondi,  1819-1820,  228. 

early  experience  of  other  surgeons,  228. 

publication  of  Grenser's  work,  progress  to  1871,  229. 

letter  from  Billroth,  230. 

Olshausen's  report  to  1877,  230. 

operations  by  Schroeder  and  Nussbaum  to  1881,  231. 

operations  by  Olshausen,  232. 

operations  by  Billroth,  tables,  234  235. 

remarks  by  Billroth,  235. 

Ovariotomy  in  the  Worth  of  Europe. 
in  Sweden  by  Skoldberg,  235. 
in  Denmark,  236. 

in  Norway,  report  by  Nicolaysen,  236-237. 

in  Russia,  first  done  by  Vanzetti,  1846,  report  of  Krassowski  on  ope- 
rations by  native  surgeons,  238. 

Ovariotomy  in  Italy. 

first  successful  case  by  Landi,  of  Pisa,  1868,  progress  since,  238. 
History  of  supposed  early  case  in  1815,  239-241. 

Ovariotomy  in  other  Countries,  India  and  the  Colonies,  241. 
Ovariotomy  in  America,  242. 


CHAPTER  VI. 

OVARIAN   DISEASE  IN   ENGLAND,  AND  THE   CONDITIONS  AFFECTING  THE 
OPERATION   OF  OVARIOTOMY. 

Statistics  of  Ovarian  Disease. 

deaths  from  ovarian  dropsy,  243. 

deaths  from  ovariotomy,  243. 

progress  of  registration,  proportion  of  ovarian  disease  among  female 

population,  244. 
mortality  of  ovarian  disease  in  England,  remarks  by  Dr.  Ogle,  245-246. 

The  Question  of  Operative  Treatment. 

conditions  which  admit  of  temporary  relief,  247. 

conditions  which  indicate  the  jjropriety  of  surgical  interference,  248. 


CONTENTS  XIX 

reasons  for  not  delaying  ovariotomy,  249-250. 

conditions  affecting  ovariotomy,  251. 

size,  252. 

adhesions,   table  showing  the  effect   of  adhesions   upon   the   results, 

253-254. 
age,  tables  showing  influence  of  upon  results,  255-256. 
mortality  at  different  ages,  257. 
conjugal  condition,  258. 
social  condition,  259. 
comparison  of  results  in  hospital,  nursing  homes,  and  private  houses, 

260. 
influence  of  season,  261-263. 
contra- indications,  264-265. 


CHAPTER  VII. 

PREPARATION  OF   A  PATIENT  FOR  OVARIOTOMY  ;   DUTIES  OF  THE  NURSE; 
DESCRIPTION   OF   NECESSARY  INSTRUMENTS. 

circumstances  influencing  the  choice  of  time  for  operation,  266. 

every  case  must  be  judged  by  its  own  peculiarities,  physical  condition 
of  the  patient,  mental,  moral,  and  social  considerations,  266. 

importance  of  attending  to  the  secretions  of  the  patient,  medication, 
change  of  air,  267. 

choice  of  place  for  operation,  relative  mortality  in  hospital  and  private 
practice,  268. 

hospital  mortality  reduced  by  antiseptics,  269. 

ventilation  and  bedding,  269. 

nurses,  qualifications,  training,  duties  of,  270-271. 

temperature  of  room,  dress  of  patient,  and  management  immediately 
before  operation,  272. 

tables  for  operation  and  arrangement  of  the  patient,  273. 

enumeration  of  necessary  instruments  and  mode  of  disposing  of  them, 
275. 

anaesthetics,  chloroform,  methylene,  276. 

methylene  brought  forward  by  Dr.  Eichardson  and  used  for  the  first 
time  in  ovariotomy  in  1867  in  my  229th  case,  276. 

my  experience  of  it  in  about  1,500  operations,  Dr.  Junker's  apparatus, 
277. 

the  syphon  trocar  and  its  various  modifications  for  ovariotomy,  278. 

the  cautery  clamp,  279. 

cauterizing  irons  and  apparatus,  280-281. 

the  chain  ecraseur  in  ovariotomy,  281. 

division  of  the  pedicle  by  twisting,  281. 

artificial  light  sometimes  necessary,  lamps  and  reflectors,  282. 

other  instruments  required — torsion- forceps,  pressure-forceps  for  tem- 
porary suppression  of  bleeding,  my  large  pressure-forceps  for 
compressing  the  pedicle  before  ligature,  283-284. 


XX  CONTENTS 


CHAPTER  VIII. 

THE  OPERATION  OF  OVARIOTOMY;  DIVISION  OF  THE  ABDOMINAL  WALL; 
SITUATION  AND  LENGTH  OF  INCISION;  SEPARATION  OF  THE  CYST; 
EMPTYING  AND  REMOVAL. 

position  of  the  surgeon,  assistants,  and  nurses,  285. 

selection  of  the  linea  alba  for  the  incision  in  all  my  cases,  and  by  most 

other  surgeons,  285. 
incisions  practised  by  early  operators,  286. 
advantages  of  choosing  the  linea  alba  when  practicable,  287. 
structures  divided  in  the  linea  alba,  288. 
structures  divided  when  the  incision  passes  through  one  of  the  recti 

muscles  or  along  one  of  the  linea?  semilunares,  289. 
anatomical  account  of  the  parts  concerned  in  the  incisions,  290-291. 
incision  through  the  integuments,  292. 
mode  of  opening  the  peritoneum,  293. 
important  not  to  puncture  the  cyst  at  same  time,  293. 
double  sharp  hook  of  Adams  and  Key's  director,  293. 
influence  of  the  length  of  the  incision,  tables  of  1.000  cases,  294. 
long  incision  preferable  to  incomplete  operation,  comparative  advan- 
tages and  mortality,  295. 
precautions  in  opening  the  abdominal  cavity,  296. 
recognition  of  an  ovarian  tumour  when   exposed,   sometimes   made 

difficult  by  adhesions,  296. 
importance  of  arresting  bleeding  before  opening  the  peritoneum,  use 

of  pressure-forceps,  ligatures,  296. 
separation  of  cystic  adhesions,  generally  yield  to  gentle  manipulation, 

cutting  rarely  necessary,  when  so,   great  precaution  required  to 

avoid  wounding  viscera,  297. 
how  to  act  in  case  of  accidental  wound  of  intestine,  298. 
tapping  the  cyst,  mode  of  using  the  syphon  trocar,  298. 
precautions  to  be  used  when  withdrawing  the  trocar,  299. 
extraction  of  the  cyst,  manoeuvre  for  preventing  prolapse  of  the  viscera, 

299. 
breaking  up  of  large  multilocular  cysts,  300. 
use  of  large  flat  sponge,  301. 


CHAPTER   IX. 

TREATMENT   OF   THE   PEDICLE;   SPONGING   OF    THE   PERITONEUM;   CLOSING 
OF   THE  WOUND  ;  ACCIDENTS  DURING   OPERATION. 

treatment  of  pedicle  either  intra-peritoneal  or  extra-peritoneal,  302. 

combined  plan  adopted  by  early  operators,  302. 

intra-peritoneal  method  originated  by  Dr.  Nathan  Smith  in  1821,  using 
ligatures,  302. 

various  modes  of  securing  the  pedicle  when  the  intra-peritoneal  treat- 
ment is  followed,  303. 


CONTENTS  xxi 

clamp  or  ligatures  used  for  extra-peritoneal  treatment,  303. 

clinical  remarks  made  in  1868  in  reference  to  the  use  of  the  clamp,  304. 

changes  in  the  pedicle  and  ligatures  when  confined  in  the  peritoneal 

cavity,  305. 
experiments  of  Spiegelberg  and  Waldeyer  on  the  effect  of  foreign  bodies 

enclosed  in  the  peritoneal  cavity,  306. 
on  the  capsulation  of  ligatures,  307. 
on  the  local  effects  of  ligatures,  308. 

on  the  reparation  of  the  cut  surfaces  of  uterine  tissue,  308. 
on  accidental  adhesions  of  granulating  tissues,  309. 
effect  of  ligatures  on  the  pedicle,  examination  of  ligatures  after  ovari- 
otomy, 310. 
observations  of  the  same  author  on  the  condition  of  cauterized  stumps, 

311. 
observations  of  Maslowsky  on  the  structural  changes  in  cauterized  and 

ligatured  stumps,  312-315. 
consideration  of  the  objections  to  the  clamp,  or  extra-peritoneal  mode  of 

treatment  of  the  pedicle,  316. 
treatment  of  the  pedicle  eclectic,  but  since  antiseptics  almost  exclusively 

intra-peritoneal,  317. 
choice  between  cautery  and  ligatures,  318. 

importance  of  transfixing  the  pedicle  when  ligatures  are  used,  318. 
manner  of  applying  them,  318. 
question  of  tightness  of  ligatures,  319. 
ends  of  ligatures  how  dealt  with,  320. 
material  for  ligatures  and  mode  of  preparing  silk,  320. 
acupressure  of  the  pedicle  once  tried  by  Simpson  successfully,  321. 
division  of  the  pedicle  by  the  ecraseur,  322. 
the  cautery  alone  often  fails  in  etopping  bleeding  from  large  vessels — 

same  defect  with  the  ecraseur,  322. 
combination  of  crushing  and  cautery  as  introduced  by  Clay,  of  Birming- 
ham, and  practised  by  Keith  effectual,  322. 
drawbacks  to  the  use  of  the  cautery,  322. 
Clay's  cautery  clamp  and  irons,  modifications  of,  electric  cautery,  and 

Paquelin's  cautery,  323. 
my  clamp  as  formerly  used  in  intra-peritoneal  treatment  of  the  pedicle, 

324-325. 
results  of  various  modes  of  treating  the  pedicle,  tables  of  1,000   cases, 

326-327. 
after  securing  the  pedicle,  precautions  to  be  taken  for  preventing  con- 
tents of  cyst  passing  into  the  abdominal  cavity,  to  arrest  bleeding 

from  the  vessels  of  adhesions,  327. 
examination  of  the  second  ovary  and  uterus,  and  exploration  of  the 

abdominal  cavity  before  closing  the  wound,  328. 
cleansing  the  peritoneal  cavity,  use  of  sponges,  removal  of  blood-clots 

and  fluids,  329. 
closure  of  the  wound,  early  practice,  present  use  of  carbolized  silk,  mode 

of  inserting  sutures,  importance  of  including  peritoneum  in  the 

sutures,  330. 
external  dressings,  arrangement  of  the  patient,  and  management  of  the 

stage  of  reaction,  331. 


Xll  CONTENTS 

Accidents  after  Operation. 

fainting,  a  few  cases  after  early  operations,  none  in  second  series,  331. 

shock  and  haemorrhage,  332. 

suppurating  and  burst  cysts  have  not  much  affected  the  success  of  the 

operation,  332. 
injuries  to  viscera,  cases  and  practical  lessons,  333. 
results  of  injuries  to  spleen,  liver,  and  kidney,  334. 
importance  of  taking  account  of  the  forceps  and  sponges  before  closing 

the  wound,  335. 
cases  in  illustration,  336. 


CHAPTER  X. 

ON  THE  REMOVAL  OP  BOTH  OVARIES  AT  ONE  OPERATION. 

importance  of  examining  both  ovaries  in  an  operation  of  ovariotomy, 

circumstances  determining  what  to  do  when  appearances  of  disease 

are  seen  in  the  second,  337. 
additional  danger  from  removing  both  ovaries,  proportional  mortality 

in  my  practice,  338. 
precautionary  removal  of  a  healthy  second  ovary  to  be  refused,  338. 
puncturing  of  distended  follicles,  339. 

statistics  of  removal  of  both  ovaries  at  same  operation,  339,  340. 
treatment  of  the  two  pedicles,  results  of  various  modes  of  securing  the 

two  pedicles,  341. 
table  of  1,000  cases  of  completed  ovariotomy,  342-393. 


CHAPTER  XI. 

ON   OVARIOTOMY  PERFORMED  TWICE  ON   THE   SAME  PATIENT. 

first  case  in  which  I  performed  this  operation  in  1863,  details  and  result 

of  the  second  operation,  394-397. 
lessons  suggested  by  the  history  of  this  case,  398. 
second  case  as  reported  in  the  '  Transactions  '  of  the  Medico-Chirurgical 

Society,  399-402. 
subsequent  history  of  patient,  403. 
details  of  another  case,  second   operation  after  an  interval  of  seven 

years,  403-407. 
fourth  case,  first  operation  with  the  ecraseur,  408. 
history  after  first  operation,  409. 

second  operation  with  description  of  the  tumour,  410  411. 
mention  of  nine  other  cases,  412. 

side  on  which  the  disease  is  most  frequently  found,  412. 
table  of  thirteen  cases  in  which  ovariotomy  was  done  twice,  413. 
proportion  of  concurrent  disease  in  both  ovaries,  414. 
recurrence  of  disease  in  ovary  remaining  after  first  operation,  415. 


CONTENTS  XX111 

CHAPTER  XII. 

ON   THE   TREATMENT   OP   PATIENTS  AFTER   OVARIOTOMY. 

local  conditions  for  good  nursing,  416. 

duties  and  qualifications  of  a  nurse,  417. 

use  of  catheter,  opiates,  stimulants,  417. 

pulse,  temperature,  and  secretions,  417. 

medical  treatment,  418. 

surgical  treatment,  examination  and  dressing  of  the  wound,  419. 

management  and  removal  of  sutures,  420. 

treatment  of  pedicle  when  clamp  has  been  used,  421. 

symptoms  indicating  collection  of  fluid  in  the  peritoneum,  Kceberle's 

drainage  tubes,  Peaslee's  injections  into  peritoneum,  422. 
drainage  and  injections,  Scanzoni's  trocar,  423. 
case  of  vaginal  drainage,  424. 
the  danger  of  puncture  much  exaggerated,  mode  of  fixing  canula  in 

drainage  cases,  425. 
symptoms  caused  by  obstructed  intestines,  425. 
case,  with  post-mortem  examination,  426-427. 
obstruction  followed  by  perforation,  428. 
reopening  abdomen  in  cases  of  intestinal  obstruction,  429. 
small  intestines  in  Douglas's  pouch,  430. 

adhesions  there  to  pedicle  sometimes  cause  of  obstruction,  431. 
obstruction  followed  by  faecal  fistula,  431. 
report  of  cases,  431-434. 

adhesion  of  intestines  to  ligatured  pedicle  influenced  me  in  favour  of 
extra- peritoneal  treatment,  change  of  views  and   practice  since 
antiseptics,  435. 
tetanus  after  ovariotomy,  my  experience  of,  435. 
reports  by  Lyman  and  Olshausen,  436. 
notes  of  my  four  cases,  three  occurred  at  early  date,  one  in  1878,  none 

since,  436. 
generally  attributable  to  chill  from  currents  of  air,  437. 
treatment,  only  successful  case  in  my  practice  treated  with  Woorara, 
opinion   of  Olshausen,  pathological  report  by  Harris  and  Doran, 
437. 

CHAPTER  XIII. 

OVARIOTOMY   DURING  PREGNANCY. 

dangers  arising  from  the  complication  of  ovarian  disease  with  pregnancy, 
438. 

practical  questions  in  such  cases,  doing  nothing,  induction  of  prema- 
ture labour,  tapping,  ovariotomy,  438. 

natural  course  of  pregnancy  and  labour  in  such  cases  exceptional,  439. 

accidents  to  be  apprehended,  439. 

three  cases  of  death  from  spontaneous  rupture  of  ovarian  cysts  during 
pregnancy,  439-443. 


XXIV  CONTENTS 

two  cases  of  successful  ovariotomy  during  pregnancy,  444. 

tapping  during  pregnancy,  case,  444. 

case  of  ovariotomy  and  Cesarean  section,  446. 

unsuspected  pregnancy  sometimes  discovered  during  ovariotomy,  cases, 

practical  questions,  446. 
practice  to  be  followed  in  the  event  of  an  accidental   opening  of  the 

uterus,  446. 
case  of  ovariotomy  at  the  fourth  month  of  pregnancy,  447. 
ovariotomy  at  the  third  month  of  pregnancy,  448. 
ovariotomy  at  the  second  month  of  pregnancy,  449. 
removal  of  ovarian  fibroid  during  pregnancy,  450-452. 
five  other  cases  of  ovariotomy  during  pregnancy,  452-454. 
practical  conclusions,  454-455. 
table  of  ten  cases,  456. 


CHAPTER  XIV. 

ON   INCOMPLETE  OVARIOTOMY  AND  EXPLORATORY  INCISIONS. 

uncertain  record  of  early  cases  of  ovariotomy  and  incomplete  operations, 
my  resolution  from  the  first  to  publish  every  case  whether  complete 
or  incomplete,  457. 

has  resulted  in  giving  an  opportunity  of  forming  a  correct  estimate  of 
the  progress  and  value  of  the  operation,  remarks  on  the  tables  of 
cases  of  incomplete  operations  coincident  with  my  first  series  of 
500,  458. 

remarks  upon  the  total  number  of  my  incomplete  operations,  have 
almost  always  confirmed  previous  suspicions,  the  general  accuracy 
of  diagnosis  at  the  present  time,  other  surgical  investigations  and 
operations  subject  to  similar  uncertainty,  459. 

proportion  and  diminishing  frequency  of  incomplete  operations,  460. 

results  of  incomplete  operations  to  the  year  1872,  460. 

three  cases  in  which  the  incomplete  operation  was  followed  by  re- 
storation to  health,  461-462. 

result  of  33  cases  of  incision  and  incomplete  operation  during  the  time 
of  my  second  series  of  500  cases  of  ovariotomy,  463. 

details  of  case  of  recovery  and  recurrence  after  five  years,  463. 

procedure  when  completion  of  ovariotomy  is  impossible,  464. 

CHAPTER  XV. 

RECENT  EXTENSIONS  OF  OVARIOTOMY. 

castration  not  a  practice  of  civilized  life,  465. 

Battey's  proposal   in  1872  made  independently  of  any  knowledge  of 

Blundell's  suggestion  in  1823,  465. 
a  proceeding  not  in  accordance  with  scientific  principles,  but  expedient, 

object  proposed  by  Battey,  Hegar's  extension  of  the  suggestion, 

report  of  cases  by  Dr.  Paul  St.  Munde,  466. 
my  own  experience  confined  to  four  cases,  466. 


CONTENTS  XXV 

principle  of  Battey's  operation  limited  in  its  application  and  liable  to 
abuse,  Hegar's  suggestion  less  questionable,  467. 

conditions  justifying  the  operation  of  removal  of  the  ovaries  very  rare, 
as  shown  by  Battey's  experience  as  well  as  my  own,  467. 

report  of  my  first  case  in  1878,  468. 

conclusions  drawn  from  consideration  of  this  case  and  subsequently 
confirmed,  vaginal  oophorectomy  exceptional,  the  abdominal  sec- 
tion to  be  preferred,  cautions  as  to  the  performance  of  both 
operations,  469. 

operation  not  repeated  for  nearly  four  years  ;  my  second  operation  in 
1881,  469. 

protest  against  the  frequency  of  this  operation,  Dr.  Weir  Mitchell's 
treatment  of  the  cases  often  selected  for  it,  Dr.  Playfair's  remarks, 
470. 

Dr.  Barnes  on  hernia  of  the  ovary  justifying  oophorectomy,  remarks 
by  Mr.  Hulke  and  Mr.  Langton  ,•  numbers  given  by  Agnew,  471. 

CHAPTER  XVI. 

RESULTS  OP  OVARIOTOMY,  AND    SUBSEQUENT    HISTORY    OP    PATIENTS  WHO 

RECOVERED. 

the  principle  of  the  operation  justified  by  the  results,  472. 

mortality  less  than  that  after  most  capital  operations,  restoration  to 
perfect  health  more  frequent,  472. 

fears  that  patients  after  ovariotomy  would  suffer  some  special  incon- 
veniences imaginary,  473. 

correspondence  with  patients  after  ovariotomy,  circular  sent  to  all  pa- 
tients who  had  recovered  after  ovariotomy,  473. 

summary  of  the  answers  returned,  numbers  of  living  and  dead,  cause 
of  deaths  since  recovery  after  operation,  number  of  children  born 
of  women  married  at  time  of  operation,  number  of  women  single 
at  time  of  operation  and  married  since,  474. 

number  of  children  result  of  these  marriages,  475. 

case  reported  by  Mr.  Whitmarsh,  of  Hackney,  475. 

condition  after  removal  of  both  ovaries,  peculiarities  of  a  few  cases, 
475-476. 

such  an  inquiry  after  a  capital  operation  unique,  476. 

health  of  patients  generally  restored,  476. 

remaining  ovary  found  to  perform  its  functions  naturally,  477. 

recurrence  of  ovarian  disease  not  common,  478. 

proportion  in  my  practice,  478. 

first  operation  no  bar  to  the  performance  of  a  second  if  necessary,  478. 

CHAPTER  XVII. 

ON   UTERINE  TUMOURS. 

the  practice  of  ovariotomy  has  led  to  a  better  acquaintance  with  the 

prevalence  of  uterine  tumours,  479. 
many  of  the  largest  abdominal  tumours  are  uterine,  479. 


XXVI  CONTENTS 

early  errors  of  diagnosis,  pedunculate  uterine  fibroids  sometimes  re- 
moved under  the  impression  that  ovariotomy  had  been  done,  479. 

physical  signs  often  much  the  same  in  the  two  classes  of  tumours,  480. 

history  of  the  case  seldom  affords  much  information,  480. 

age,  uterine  tumours  perhaps  more  common  in  advanced  life,  and 
ovarian  cysts  among  young  people,  480. 

physiognomy  and  complexion  as  aids  in  diagnosis,  481. 

evidence  from  inspection,  general  enlargement,  state  of  the  umbilicus, 
condition  of  the  superficial  veins,  movements  of  the  tumour, 
appearances  during  change  of  posture,  481. 

measurement  and  palpation,  482. 

percussion  and  auscultation,  483. 

vaginal  and  rectal  examination,  484. 

abnormal  arterial  impulse,  simulation  of  aneurismal  disease  in  some 
uterine  cases,  484. 

case  by  Dr.  Bailey,  of  Louisville,  K.,  485. 

change  of  position  of  the  uterus,  uterine  sound,  485. 

what  may  be  learnt  by  rectal  examination,  486. 

effect  of  movement  of  the  tumour  upon  the  position  of  the  uterus,  486. 

ovarian  and  fibroid  tumours  of  the  uterus  sometimes  co-exist,  487. 

case  of  fibroid  tumours  of  the  uterus  impeding  labour,  488. 

case  of  fibroid  outgrowths  from  the  uterus  removed  by  gastrotomy,  re- 
port by  Dr.  Braxton  Hicks,  490. 

removal  of  fibro-cystic  tumour  of  the  uterus,  with  reports  on  the  struc- 
ture, by  Drs.  Ritchie  and  Gordon,  491-494. 

nature  of  the  tumours  sometimes  revealed  by  examination  of  the  fluid 
obtained  by  tapping,  495. 

opinions  in  1868,  495. 

result  of  ten  years'  experience,  496. 

the  subject  introduced  into  the  Hunterian  Lectures  at  the  College  of 
Surgeons  in  1878,  496. 

case  of  operation  in  1878,  497-498. 

removal  of  solid  fibroid  tumour  weighing  70  pounds,  operation,  report 
on  tumour,  and  history  of  patient,  499-502. 

modifications  in  operative  procedure  during  the  two  following  years, 
use  of  antiseptics,  and  union  by  suture  of  the  peritoneal  edges  of 
the  divided  uterine  wall,  paper  read  at  the  Cambridge  meeting  of 
the  British  Medical  Association,  1 880,  502. 

fibro-cystic  tumour  containing  13  pints  of  fluid,  503. 

large  pressure-forceps  introduced  for  compressing  the  tissues  at  the 
base  of  a  tumour,  504. 

reports  of  several  successful  cases,  504-508. 

exploratory  incision  in  cases  of  uterine  tumour,  509. 

table  of  cases  of  removal  of  uterine  tumours,  512-515. 

table  of  cases  of  explorator}7  incision  and  partial  removal  of  fibro-cystic 
tumours  of  the  uterus,  516-517. 


CONTENTS  XXV11 


CHAPTER  XVIII. 

ON   PARTIAL   AMPUTATION  AND   ON   COMPLETE   EXCISION   OP   THE 
UTERUS. 

the  names  of   Blundell  and  Freund  associated  with  excision  of  the 

entire  uterus,  518. 
that  of  Porro  with  partial  amputation  of  the  pregnant  uterus,  518. 
my  case  of  complete  excision  of  the  pregnant  uterus,  not  only  the  first 

of  the  kind  in  Great  Britain  but  unique,  518. 
details  of  the  case,  state  of  the  patient,  519. 
account  of  the  operation,  519-20. 
reports  on  the  removed  parts  by  Mr.  Doran,  521-2. 
after  treatment  and  condition  of  the  patient,  523. 
suggestions  for  future  operations,  524. 
suggestions  by  Nunn  and  Miiller  as  to  dividing  uterus  before  excision, 

525. 
drainage  not  necessary,  526. 
combined  vaginal  and  abdominal  operation  for  removal  of  non-gravid 

uterus,  526-7. 
amputation  by  the  vaginal  method,  527. 
compression  of  aorta,  527. 

forceps  instead  of  ligatures,  mode  of  controlling  haemorrhage,  527. 
Blundell 's  operations  fifty  years  ago,  527. 
report  of  94  cases  of  Freund's  operation,  collected  by  Olshausen,  1880, 

528. 
report  of  44  cases  of  vaginal  operation,  528. 
case  of  excision  by  Bischoff,  528. 
letter  from  Billroth  with  case  of  excision,  529. 
practice  in  cases  of  gravid  or  non-gravid  cancerous  uterus,  529. 
excision  the  only  resource  when  the  body  or  fundus  of  the  uterus  is 

affected,  530. 


ERRATA. 

Page  15,  line  7  from  foot,  for  Hugier  read  Huguier 
Page  198,  line  24,  for  membrane  read  membranes 


LIST    OF    ILLUSTKATIONS 


PAGE 

Extra-ovarian  cyst  of  broad  ligament        .......  14 

Portion  of  a  multiple  ovarian  cyst 20 

Diagrammatic  representation  of  an  advanced  proliferous  cyst ...  23 

Mode  of  development  of  cysts  from  the  epithelium 24 

Tubular  glands  partially  enclosed  in  stroma 28 

Cysts  and  compound  masses  of  glands  imbedded  in  wall  of  parent  cyst  .  29 

Secondary  cysts  projecting  through  the  wall  of  a  multilocular  tumour  .  30 
Formation  of  secondary  cysts  by  tubular  processes  given  off  from  cysts 

in  thicker  portions  of  stroma 31 

Vertical  section  through  a  cauliflower  mass  showing  mode  of  formation 

of  cysts 32 

Cysts  in  foetal  ovary 34 

Diagrammatic  section  of  a  dermoid  and  compound  cyst  ....  42 

Clots  in  the  corroded  vessels  of  cyst  wall 45 

Section  of  the  trabecules  of  a  multilocular  tumour 46 

Dendritic  growths  on  inner  surface  of  cyst  wall 53 

Antemic  patches  in  wall  of  cyst         .         .         .        ...        .         .69 

Physiognomy  of  patient  with  ovarian  disease 82 

Portrait  showing  compression  of  thorax  by  ovarian  tumour      ...  83 

Portrait  showing  distension  of  abdomen  and  expansion  of  the  ribs      .     .  84 

Portrait  of  patient  with  umbilical  hernia 85 

Situation  of  clear  and  dull  sounds  in  typical  cases  of  ascites  and  ovarian 

dropsy - 88 

Proliferating  cells  from  abdominal  fluids 98 

Case  of  hysteric  tympanites — abdomen  distended 107 

Same  patient  under  chloroform — abdomen  collapsed        .         .         .         .108 

Same  patient,  returning  consciousness — abdomen  inflating  .  .  .  .  109 
Portrait  of  woman  with  peritoneal  hjrdatid       .         .        .        .         .         .116 

Portrait  of  child  with  cancer  of  kidney 127 

Position  of  cyst  in  case  of  renal  disease 133 

Retroverted  gravid  uterus  with  distended  bladder        .        .         .        ,     .  149 

Mr.  Charles  Thompson's  trocar ;  same  trocar  with  syphon  tube  opened    .  160 

Syphon  trocar,  position  of,  in  tapping 162 

Wire  for  fixing  canula  in  vaginal  drainage           . 169 


XXX  LIST   OF   ILLUSTRATIONS 

PAGE 

Portrait  of  Dr.  McDowell,  of  Kentucky 187 

Clamp  on  pedicle 202 

Parallel  clamp 203 

Original  ovariotomy  couch 206 

Supposed  ovarian  tumour  removed,  1815,  by  Dr.  Emiliani,  of  Faenza      .  240 

Present  arrangement  of  patient  for  ovariotomy 274 

Nelaton's  vulsellum 278 

Division  of  pedicle  by  cautery '  280 

Pressure -forceps,  small 283 

Pressure-forceps,  large 284 

Direction  of  incision  in  abdominal  wall 286 

Diagram,  layers  divided  in  an  incision  through  the  linea  alba  .        .         .288 

Diagram,  through  one  of  the  recti  muscles 289 

Diagram,  along  one  of  the  linese  semilunares 289 

Position  of  scalpel  in  making  abdominal  incision 292 

Hook  for  raising  the  peritoneum 293 

Division  of  the  peritoneum 294 

Separation  of  adhesions 297 

Introduction  of  the  syphon  trocar 298 

Extraction  of  the  cyst  through  the  abdominal  incision    ....  299 

Breaking  up  the  interior  of  the  cyst 300 

Ligatures   on  pedicle,  detached  ligature   from   case  reported   by   Mr. 

Bryant 318 

Compression  of  the  pedicle  and  vessels  by  needles,  after  Simpson       .    .  321 

Supposed  internal  view  of  same 321 

Closure  of  the  clamp  on  the  pedicle 324 

Turning  the  screw  of  the  clamp 324 

Abdominal  wound  closed  by  sutures,  the  clamp  in  position          .         .     .  325 

The  cicatrix  three  weeks  after  operation 421 

Scanzoni's  trocars 423 

Case  of  drainage  of  the  pelvis  by  vagina 423 

Case  of  intestinal  obstruction 427 

Vertical  section  of  pelvis  and  pelvic  organs 429 

Horizontal  section,  view  of  pelvic  organs  from  above       ....  430 

Fibroid  outgrowth  from  the  uterus 489 

Portrait  of  patient  with  uterine  tumour 500 

Gravid  uterus  removed  by  abdominal  section,  back  view  of  preparation 

in  college  museum 521 

Same,  front  view 522 


OVARIAN  AND  UTERINE  TUMOURS 


INTRODUCTION 

The  only  phenomena  connected  with  the  human  race  which 
have  remained  unchanged  from  the  beginning  are  those  of 
reproduction.  Form,  colour,  type,  language,  habitudes,  cha- 
racter have  all  been  subject  to  variations,  as  the  influence  of 
ages  has  been  brought  to  bear  upon  succeeding  generations. 
But  such  as  the  ovum  was  in  the  beginning,  such  it  is  now, 
and  we  may  presume  that  whatever  modifications  other  organs 
have  undergone  we  see  the  ovary  in  its  pristine  form.  Nor 
is  this  a  matter  to  be  wondered  at.  Essentially  the  central 
point  to  which  the  energy  of  universal  life  is  directed  is  that 
of  procreation.  The  aim  is  unique  and  the  means  are  uniform. 
The  primary  cell  of  the  being  is  the  dominant  cell,  and  on  it 
depends  the  continuance  of  the  species.  All  the  composite 
structures  evolved  from  it  have  reference  through  nutrition 
and  mind  force  to  its  successors.  In  its  turn  the  condition  of 
this  cell-nest  affects  the  life  and  well-being  of  the  race,  and  it 
is  with  its  deviations  from  natural  states  that  we  have  to  do  in 
ovarian  pathology  and  surgery. 

In  proceeding  to  estimate  the  frequency  and  importance 
of  the  diseases  of  the  ovaries,  we  have  to  consider  the  wonder- 
ful series  of  periodical  processes  which  go  on  in  women  every 
month  for  some  thirty-five  years  of  life  :  sometimes  without 
any  interruption  by  pregnancy,  sometimes  interrupted  by 
many  pregnancies,  either  carried  on  to  the  full  term  or 
arrested  at  different  stages ;  followed  by  lactation  for  periods 
variously  prolonged,  and  perhaps  suddenly  stopped  by  the 
death  of  the  child  or  by  another  pregnancy;  attended  by  losses 

B 


1 


2  PERIODICITY    OF    FEMALE    LIFE 

of  blood  of  less  or  greater  quantity,  and  ceasing  usually  from 
forty-five  to  fifty-five   years   of  age,   after  more  or  less  irre- 
gularity.    We  have  to  remember  that  at  each  menstrual  period 
one  or  other  ovary  becomes  swollen ;  that  one  or  more  of  its 
ovisacs  enlarges,  opens,  and  admits  of  the  escape  of  the  ovum 
it  contained  ;  that  the  fimbrial  end  of  the  Fallopian  tube  grasps 
the  ovary,  receives  the  ovum,  and  allows  of  its  passage  into  the 
uterine  cavity ;    that  the  uterus  itself  receives  an   increased 
supply  of  blood,  and  that  its  mucous  membrane  undergoes  a 
series  of  exfoliative  changes.     We  must  consider  further  how 
these  periodical  processes  are  associated  with  much  that  is  of 
supreme  importance  in  the  state  of  the  nervous  centres  and  in 
the   mental   condition  of   woman;    that   the  normal   process, 
instead  of  recurring  at  regular  intervals  and  ceasing  in  a  few 
days,  may  be  abnormally  prolonged,  and  may  recur  at  most  un- 
certain  periods;   and   that    evolution  and  involution  may   be 
both  affected  by  pregnancy  and  lactation.     When  we  bear  in 
mind  all  these  highly  complex  conditions,  processes,  and  rela- 
tions, the  marvel  is  not  that  ovarian  diseases  should  be  so  fre- 
quent,  but  that  so  many  women   pass   through  life   without 
suffering  from  them. 

The  ovary  is  an  organ  which  passes  through  a  series  of 
changes  during  the  whole  of  female  existence.  Childhood  and 
youth  are  taken  up  with  its  development,  and  it  is  then  small, 
elongated,  with  a  smooth  unbroken  surface,  and  moderate  sup- 
ply of  blood.  At  puberty  functional  activity  takes  the  place  of 
growth,  and  there  is  greater  turgescence,  more  rotundity  of  form, 
an  often-repeated  laceration  and  scarring  of  the  outer  coats,  re- 
placement of  the  natural  contents  of  the  ovisacs  by  the  vestiges 
of  the  evolution,  accompanied  by  a  constant  tendency  to  irregu- 
larity of  function  and  to  disease.  After  the  period  of  active 
ovulation  has  passed,  old  age  brings  with  it  the  usual  retro- 
grade action,  and  marks  of  atrophic  decay.  The  gland  is  found 
small,  pale,  shrivelled,  nodular,  and  seamed  with  scars.  With 
this  collapse  of  the  organ,  and  consequent  decline  of  fecundity, 
the  distinguishing  peculiarities  of  feminine  character  and  con- 
figuration are  gradually  modified. 

During  the  period  of  generative  activity,  the  repeated  clear- 
ing out  of  the  Graafian  follicles  is  followed  by  reparative  action. 
The  greater  number  of  ova  escape  the  seminal  contact  or  influ- 


GRAAFIAN   VESICLES  3 

ence.  In  this  case  the  local  exacerbation  ceases,  and  no  traces 
are  left  in  the  uterus  of  the  abortive  process,  while  rapid 
cicatrization  of  the  collapsed  follicle  ensues  in  the  now  qui- 
escent ovary. 

The  appearances  which  this  cicatrization  occasions  are  known 
as  the  corpora  lutea.  That  which  results  from  the  exit  of  an 
ovum  which  does  not  become  impregnated  is  less  marked  in  its 
characteristics,  and  is  said  to  be  a  false  corpus  luteum.  Every- 
thing settles  down  quietly  after  the  failure  of  conception  :  inor- 
dinate vascular  action  subsides  in  the  ovary  as  in  the  other 
excited  organs,  and  the  emptied  Graafian  vesicle  has  simply  to 
go  through  the  process  of  healing.  Blood  is  effused  into  the 
cavity  of  the  sac  at  the  time  of  rupture,  coagulates,  forms  a 
clot,  and  is  enclosed  in  the  collapsing  tunics  of  the  follicle. 
The  true  ovisac,  with  its  epithelial  lining,  is  thrown  into  puckered 
folds  by  the  greater  contractility  of  the  outer  layer,  some  fibrous 
exudation  takes  place,  and  the  clot  is  closely  packed  in  the 
centre.  Transverse  section  shows  the  reddish  mass  of  blood 
enclosed  in  the  corrugated  folds  of  the  yellow  layer,  from 
which  the  body  derives  its  name ;  and  this  is  surrounded 
by  the  whitish  coat  of  the  follicle  in  contact  with  the  stroma  of 
the  ovary.  But  atrophic  changes  rapidly  set  in  :  the  capillary 
vessels  shrink,  the  mass  of  cells  and  their  matrix  membrane 
undergo  fatty  degeneration,  and  the  clot  disappears  by  absorp- 
tion, so  that  before  the  recurrence  of  another  period  only  a 
stellate  cicatrix  is  to  be  found  retracted  in  the  substance  of  the 
ovary. 

On  the  contrary,  when  conception  and  pregnancy  follow  the 
escape  of  the  ovum,  the  ovary  is  involved  with  all  the  other 
associated  organs  in  the  state  of  nutrient  energy,  and  although 
the  new-formed  corpus  luteum  is  equally  destined  to  oblitera- 
tion, the  event  is  delayed  until  some  months  after  parturition. 
The  morphological  changes  are  for  a  time  not  decidedly  retro- 
grade. Active  circulation  goes  on  in  the  outer  coats,  and 
exfoliation  of  epithelial  cells  continues,  so  that  the  yellow 
convoluted  layer  thickens  and  encroaches  on  the  central  space, 
where  the  condensed  clot  becomes  more  or  less  organised. 
This  state  of  abnormal  nutritive  effort  attains  its  highest  point 
about  the  fourth  month  of  pregnancy.  But  though  some  small 
portion  of  young  fibrous  and  connective  tissues  may  be  formed  in 

B    2 


4  OVARIAN    ANOMALIES 

connection  with  the  coats  of  the  ovisac,  and  thus  render  the 
substance  of  the  corpus  luteum  more  compact  and  organised 
for  a  time,  yet  no  true  progressive  structural  development  takes 
place.  No  new  histological  elements  have  presented  themselves, 
and  no  new  combinations  of  the  tissues  have  resulted,  so  that 
all  the  apparent  growth  consists  in  the  temporary  hypersemia 
of  the  original  coats  of  the  follicle,  the  elimination  of  a  small 
quantity  of  embryonic  structures  from  them,  the  accretion  of 
epithelial  cells  and  fatty  matter,  and  the  partial  metamorphosis 
of  the  central  clot  into  a  tissue  of  the  lowest  form  of  vitality — a 
sort  of  pseudo  lining  membrane  for  the  cavity  caused  by  its 
conversion.  From  this  point  nothing  very  different  from  the 
atrophic  degeneration  of  the  corpus  luteum  of  menstruation 
happens ;  but  the  stages  of  retrogression  are  slow  and  prolonged 
to  the  end  of  pregnancy  or  through  the  two  or  three  earlier 
months  of  lactation,  the  variation  evidently  depending  upon 
the  amount  of  conservative  nutrient  energy  directed  to  the 
part.  It  may  be  understood  from  this  physiological  explanation 
of  the  origin  and  end  of  corpora  lutea  how  these  two  succes- 
sive conditions  of  imperfect  nutritive  effort  and  atrophic  decay 
may,  if  misdirected  or  carried  to  excess,  give  rise  to  various 
forms  of  disease,  either  of  hypertrophic  growth  or  malignant 
degeneration. 

Absence  of  the  ovaries,  or  their  imperfect  development,  may 
occasionally  be  inferred  from  some  physical  peculiarities  or 
physiological  aberrations  ;  and  the  presence  of  a  third  or  acces- 
sory ovary,  now  and  then  observed  in  the  dissecting-room  and 
on  the  operating  table,  may  probably  account  for  the  recur- 
rence of  regular  menstruation  in  spite  of  serious  disease  or 
after  the  removal  of  two  by  ovariotomy. 

The  congenital  or  accidental  displacements  of  the  ovaries 
are  from  time  to  time  the  cause  of  perplexity  to  the  surgeon, 
and  the  manipulation  in  the  necessary  examination  requires 
skill  and  care.  The  ovaries  may  be  felt  in  their  normal  posi- 
tion on  either  side  of  the  uterus,  a  little  below  the  brim  of  the 
pelvis,  between  one  finger  passed  upwards  in  the  vagina  and 
another  pressed  downwards  from  the  abdominal  wall.  It  is 
only  in  some  exceptional  cases  of  firm  vagina  or  very  tense  and 
thick  abdominal  wall  that  the  ovaries  cannot  be  made  out. 

In  order  that  this  examination  may  be  done  effectually  the 


MODES    OF    EXAMINATION  5 

patient  should  be  made  to  lie  on  her  back,  with  the  shoulders 
and  knees  raised  so  as  to  relax  the  belly,  and  both  bladder  and 
rectum  must  be  empty.  It  is  only  by  combined  internal  and 
external  examinations  that  a  normal  ovary  or  one  only  slightly 
enlarged  can  be  detected.  External  examination  alone  is  quite 
fruitless.  By  vaginal  examination  alone  a  resisting  body  may 
perhaps  be  felt  through  the  upper  part  of  the  vault  of  the 
vagina :  its  mobility  may  be  recognized,  but  nothing  more. 
Indeed  in  most  cases  the  ovaries  are  so  easily  displaced  that 
they  elude  internal  examination  alone.  Yet  two  fingers 
brought  together,  one  from  without  and  one  from  within,  may 
fix  and  feel  the  ovary  between  them.  It  is  well  first  to  find 
the  fundus  uteri  and  to  steady  it  by  one  or  two  fingers,  and 
then  by  the  combined  examination  the  ovary  is  found  near  the 
uterus,  on  one  side  of  it.  The  finger  can  be  passed  around 
it  and  it  may  be  shifted  easily  from  before  backwards,  and  less 
easily  towards  and  away  from  the  side  of  the  uterus.  It  has  a 
firm  elastic  feel,  glides  easily  under  the  fingers,  and  the  un- 
evenness  of  the  surface  may  often  be  clearly  detected. 

A  small  hard  mass  of  faeces  in  the  bowel,  a  swollen  pelvic 
gland,  a  cyst  in  the  broad  ligament,  a  dilatation  of  the  Fallopian 
tube,  or  a  small  pedunculate  outgrowth  from  the  uterus  might 
give  a  similar  impression  to  the  examining  fingers,  but  after 
some  practice  this  will  not  be  mistaken  for  the  characteristic 
feel  of  the  ovary. 

The  right  ovary  is  most  easily  reached  by  one  or  two  fingers 
of  the  right  hand  in  the  vagina,  the  left  hand  being  on  the 
abdomen ;  the  left  ovary  by  the  left  hand  being  used  for  the 
vagina  and  the  right  for  the  outside. 

Examination  by  the  rectum  is  in  some  cases  more,  in  others 
less  useful  than  by  the  vagina.  Occasionally,  when  the  rectum 
is  large  and  the  vagina  tense,  one  or  both  ovaries  may  be  dis- 
tinctly felt  by  the  rectum  and  not  by  the  vagina.  In  some 
cases,  when  the  ovaries  can  be  readily  felt  by  the  vagina  they 
cannot  be  touched  by  the  rectum.  Even  in  the  case  where 
the  ovary  is  abnormally  situated  in  Douglas's  space  it  may  be 
palpable  through  the  posterior  wall  of  the  vagina,  and  the 
fingers  of  the  hand  compressing  the  abdomen  meet  a  finger  in 
the  vagina  much  more  readily  than  one  in  the  rectum.  Ex- 
amination both  by  rectum  and  vagina  is  necessary  when  an 


6  DISPLACEMENT   OF   THE   OVARY 

ovary,  not  enlarged,  is  supposed  to  be  in  Douglas's  space,  for 
Schultze  has  known  a  gland  behind  the  rectum  to  be  felt 
through  the  vagina  and  mistaken  for  an  ovary. 

It  must  be  remembered  in  judging  of  the  size  of  an  ovary, 
that  if  small,  and  felt  through  a  thick  abdominal  wall,  it  will 
appear  to  be  larger  than  it  is,  and  that  ovaries  of  the  same  size 
felt  through  walls  of  different  thickness  may  appear  to  be  of 
different  sizes.  A  little  practice  will  be  sufficient  to  teach 
what  allowance  should  be  made  in  face  of  this  source  of  possible 
error. 

A  healthy  ovary  is  generally  insensible  to  moderate  pres- 
sure. But  touch  may  give  pain  when  there  is  no  reason  to 
suspect  inflammation  or  any  other  departure  from  a  state  of 
health.  Even  ovaries  greatly  enlarged  by  inflammation  will 
bear  considerable  pressure — a  proof  that  Oophoritis  does  not 
necessarily  extend  to  the  peritoneum;  for  when  this  mem- 
brane becomes  implicated  the  sensibility  to  pressure  is  gener- 
ally extreme.  The  diagnosis  can  only  be  made  out  with  cer- 
tainty when  the  swollen  and  painful  ovary  is  distinctly  felt  as 
a  circumscribed  lump. 

Schultze  says  he  has  often  observed  that  the  displacement 
of  the  ovary  during  inflammation  may  rather  be  into  Douglas's 
space  than  to  the  front  of  the  uterus,  and  that  on  regaining  its 
usual  volume  and  sensibility  it  has  returned  to  its  natural 
position.  In  other  cases  after  recovery  it  remains  fixed ;  and 
once  an  ovary  which  had  been  closely  adherent  to  the  uterus 
after  inflammation  was  several  months  before  it  became  again 
movable. 

The  displacements  of  the  ovary  recognized  by  this  mode  of 
double  examination  are  all  within  the  limits  of  the  abdominal 
cavity ;  but,  like  portions  of  omentum  or  intestine,  the  whole 
gland  will  sometimes  find  its  way  through  the  weak  points  of 
the  parietes,  and  we  have  to  deal  with  it  as  a  form  of  hernia, 
either  inguinal,  crural,  ischiatic,  umbilical,  ventral,  or 
vaginal.  Pott's  case  was  one  of  simple  hernia  and  abscission  ; 
but  an  ovarian  cyst  has  even  formed  outside  the  inguinal  ring, 
and  been  the  subject  of  an  extra-mural  ovariotomy  by  a  Spanish 
surgeon.  An  instance  of  this  kind  has  not  come  under  my 
notice,  but  I  do  not  see  that  it  can  offer  any  special  difficulties 
to  the  operator. 


PATHOLOGY  7 

There  is  much  truth  in  the  remark  of  Arthur  Farre  that '  of 
all  the  organs  of  the  body  the  ovary  is  perhaps  that  whose 
pathological  conditions  have  been  regarded  with  the  smallest 
amount  of  reference  to  its  natural  deranged  functions ; '  and  it 
is  not  unusual  to  hear  ovarian  hyperaemia  and  inflammations, 
either  acute  or  chronic,  spoken  of  as  more  or  less  connected  or 
dependent  on  some  metritic  action.  This  appears  to  me,  how- 
ever, to  be  as  illogical  as  it  is  unwarranted  by  fact.  Of  the 
whole  series  of  the  generative  organs,  the  ovary  is  indisputably 
the  first,  the  most  influential,  and  in  fact  the  raison  d'etre  of  all 
the  rest.  Calling  it  a  gland,  for  want  of  a  better  term,  as  the 
nidus  of  ovulation  the  tubes,  uterus,  and  vagina  are  but  acces- 
sories to  the  completion  of  its  functions  in  the  impregnation, 
incubation,  and  expulsion  of  its  product.  The  various  states  of 
hyperaemia  and  inflammation,  when  not  traumatic,  are  mostly  to 
be  traced  to  some  functional  perversion,  and  probably  are  more 
often  transmitted  than  imparted.  As  the  most  conspicuous 
member  of  the  series,  and  unfortunately  the  most  accessible, 
the  uterus  has  attracted  the  attention  and  experienced  the 
meddlesomeness  of  gynaecological  science,  and  has  had  to  bear 
the  blame  of  many  unmerited  pathological  accusations.  But 
in  ovarian  disease  it  is  the  ovary  which  is  ordinarily  from  first 
to  last  in  fault,  and  to  it  we  should  direct  our  care  and 
remedies.  The  symptoms  and  general  effects  of  these  hyper- 
aemic  and  inflammatory  conditions  of  the  ovary  are  terrible  and 
disastrous  enough  ;  but  their  special  interest  here  is  that  they 
may  be  regarded  as  too  often  the  point  of  departure  in  the 
formation  of  cystic  and  other  tumours. 


CLASSIFICATION 


CHAPTER   I 

THE   DIFFERENT   KINDS   OF    OVARIAN   TUMOURS 

Abdominal  and  pelvic  tumours  connected  with  the  female 
organs  of  generation  are  of  many  kinds,  but  those  which  es- 
pecially implicate  the  ovary  may  be  reduced  to  three  classes : 
1st,  the  adenoid  tumours,  composed  of  gland  structure  in 
variously  altered  conditions  ;  2nd,  tumours  of  a  fibrous  cha- 
racter, the  result  of  growth  from  the  connective  tissue  of  the 
organ  ;  and  3rd,  those  tumours  which  assume  a  malignant  form, 
and  are  essentially  degenerations  or  new  formations.  Other 
cystic  tumours  are  found  in  the  neighbouring  organs,  some- 
times complicating  the  diagnosis  of  ovarian  tumours,  and  re- 
quiring nearly  the  same  management  and  operative  measures. 
To  show  their  analogies  and  relations,  all  of  these  may  be 
grouped  in  the  following  manner : — 

ovarian  tumours. 

1.  Adenoid  : — a.  Hypertrophy  of  part  or  whole  of  the  gland. 

b.  Simple  cysts — enlarged  Graafian  follicles. 

c.  Multiple  cysts — cysts  in  apposition  forming 

multilocular  tumours. 

d.  Proliferous  cysts — parent  cysts  with  secondary 

cysts   growing   from   the    interior   of  cyst 
wall. 

2.  Fibrous — Growth  of  stroma  of  ovary. 

3.  Malignant  and  tubercular — Cancer,  tubercle. 

extra-ovarian  tumours, 

Cysts  of  Fallopian  tube  and  terminal  vesicle. 

Cysts  of  broad  ligament  or  vesicles  of  Wolffian  body. 


SIMPLE    OVARIAN    CYSTS  9 

Cysts  developed  from  tubules  of  parovarium. 

Cysts  developed  in  the  subperitoneal  tissue  of  the  pelvis  or 
abdomen. 

Cysts  developed  from  aberrant  ova  attached  to  the  peritoneal 
surface. 

But  for  descriptive  purposes  it  will  be  better  to  arrange  the 
simple  cysts  in  two  classes  : — 

1.  Ovarian — Enlarged  Graafian  follicles. 

2.  Extra-ovarian — a.  Cysts  of  Wolffian  body. 

b.  Cysts  of  Broad  Ligament. 

c.  Cysts  of  Fallopian  tubes. 

d.  Cysts  developed  in  the  subperitoneal 

tissue  of  the  pelvis  or  abdomen. 

e.  Cysts  developed  from  aberrant  ova. 
The  compound  adenoid  tumours  also  fall  into  two  divisions  : 

1.  Multiple,  consisting  of  cysts  aggregated  together. 

2.  Proliferous,  or  parent  cysts,  filled  with  cysts  of  secondary 

growth : — 
leaving  for  after  consideration  the  tumours  arising  from  fibrous 
and  malignant  growths. 

SIMPLE   OVAEIAN   CYSTS. 

The  simple  or  unilocular  ovarian  cysts  are  organised  sacs, 
containing  fluid,  which  grow  from  some  part  of  the  ovary  itself. 
They  commence  their  growth  as  small  vesicles,  but  no  limit 
can  be  mentioned  as  to  their  ultimate  size,  except  that  of  the 
containing  power  of  the  abdomen,  and  the  extent  to  which  the 
abdominal  walls  may  be  distended.  As  they  enlarge  and  press 
upon  the  viscera  in  contact,  enough  irritation  is  generally  set 
up  to  lead  to  the  formation  of  bands  and  layers  of  attaching 
tissue.  Often,  however,  so  little  local  disturbance  attends  the 
increase  of  the  tumours  that  they  reach  the  size  of  the  gravid 
uterus  without  any  adhesions. 

The  walls  of  even  these  enormous  sacs  are,  after  all,  in  their 
simple  forms,  only  the  continued  growths  of  some  of  the  ori- 
ginal ovarian  tissues.  No  new  elements  are  superadded.  There 
is  only  a  surplus  of  material,  malarranged  and  out  of  place. 
At  their  first  stage  of  development  into  cysts,  they  are  to  be 
seen  with  one  part  projecting  from  the  surface  of  the  ovary, 


10  STRUCTURE   OF   SIMPLE   CYSTS 

the  remainder  being  imbedded  in  its  stroma,  or  enveloped  by 
its  fibrous  tunic.     The  coats  are  then  thin,  membranous,  and 
translucent,  and  not  in  any  way  to  be  distinguished  from  the 
natural  structure  of  a  Graafian  follicle.     With  growth  comes 
greater  thickness,  opacity,  and  firmness.     The  delicate  mem- 
brane of  the  vesicle  has  changed  into  a  layer  of  fibrous  tissue, 
with  its  full  complement  of  nerves,  arteries,  and    veins ;  the 
epithelial  lining  is  more  marked  from  abnormal  reproductive 
activity  in   the  cells,  and  an    ultimate  tendency  to   irregular 
formations  ;  and  the  peritoneum  remains  always  recognizable  as 
the  outer  investment.     The  peritoneum  is  extremely  attenu- 
ated, and  cannot  easily  be  detached,  but  retains  its  delicate 
pavement   epithelium.     The    interior  has    also  sometimes  the 
smooth    glistening   appearance    of    a    serous    membrane   with 
similar  epithelium,  interspersed  here  and  there  with  groups  of 
a  few  stalked  and  ciliated  cells.     Naturally  the  most  distant 
unattached  points  of  the  sac  are  the  most  yielding,  and  become 
thinner  than  the  other  parts.     There  is  no  uniformity  of  thick- 
ness, which  in  different  cases,  or  even  in  the  same  tumour,  may 
vary  from  more  than  an  inch  to  the  extreme  bursting  point  of 
tenuity.     The  histological  elements  of  this  coat  are  identical 
with  those  of  ordinary  fibrous  tissue,  consisting  of  fibres  very 
difficult  to  disentangle,  nucleated  fibre  cells  and  granules.    The 
form  of  the  tumour,  of  course,  mainly  depends  on  the  elasticity  of 
this  layer,  and  when  freed  from  pressure  assumes  nearly  that  of 
a  globe  or  egg,  with  bulgings  irregular  according  to  the  density 
or  yielding  disposition  of  the  several  parts.     Though  as  a  rule 
receiving  an  abundant  supply  of  blood  for  nutrition  and  growth, 
the  inevitable  stretching  and  pressure  from  the  accumulation 
of  fluid,  and  consequent  interference    with  capillary    circula- 
tion, give  this  tissue  a  proneness  to  structural  degeneration, 
and  it  may  become  softened  by  fatty  transformation  or  indu- 
rated by  earthy  deposit.     The  vessels  which  supply  it  enter  at 
the  base,  enlarge  with  its  growth,  and  ramify  very  freely  on  its 
inner   surface.     They  form  a  complex  network  in  and  under 
the  peritoneum,  and  the  capillaries  passing  into  the  fibrous  layer 
traverse  it,  and  have  a  peculiar  arrangement  on  the  inside,  where 
they  form  knots  of  anastomosis  with  bulbous  dilatations  and 
terminal  pouches,  like  but  less  regular  than  those  found  in  the 
chorion.     According  to  Harris  and  Doran  they  sometimes  are 


ORIGIN    OF   SIMPLE   CYSTS  11 

the  origin  of  large  cysts.  They  undergo  many  changes,  and 
are  often  atrophied  and  completely  obliterated,  and  replaced  by 
successive  fresh  formations.  The  consequence  of  this  is,  that 
there  are  incessant  irregularities  in  the  circulation,  with  stag- 
nation and  capillary  embolism.  The  decomposed  blood  yields 
a  deposit  of  granular  hsematoid  matter  and  cholesterine,  of  a 
yellow  colour,  which  tinges  the  tissue  and  gives  it  a  brownish 
or  tawny  appearance  on  section.  Outside,  under  the  peritoneal 
covering,  the  course  of  numerous  large  and  tortuous  veins  is  to 
be  traced  plainly,  and  they  often  acquire  considerable  volume. 
Nerves,  sometimes  of  great  size,  pass  with  the  vessels  into  the 
substance  of  the  coats,  but  their  mode  of  termination  has  not  been 
made  out.  The  lymphatics,  also,  are  in  some  cases  developed 
much  beyond  their  ordinary  volume.  Generally  the  Fallopian 
tube,  enlarged  and  elongated,  stretches  over  the  surface  of  the 
tumour  and  sometimes  seems  almost  identified  with  its  sub- 
stance, the  fimbriated  extremities  being  spread  out  and  more  or 
less  attached.  In  other  instances  the  overgrown  tube  passes 
freely  along  the  walls  of  the  cyst  in  a  fold  of  peritoneum. 
However  placed,  it  mostly  shows  an  increase  of  growth  corre- 
sponding with  that  of  the  ovary. 

Many  of  the  simple  ovarian  cysts  originate  in  a  Graafian 
follicle,  either  before  or  after  its  rupture.  The  theory  that  the 
whole  energy  of  the  developmental  process  •  in  the  follicle  is 
confined  to  the  delicate  germinal  vesicle,  and  that  the  first 
impulse  to  the  formation  of  a  morbid  cyst  is  caused  by  the 
destruction  of  the  germinal  spot,  and  the  involution  of  the 
Graafian  follicle,  does  not  furnish  a  sufficient  explanation  of 
every  case.  Eokitansky  and  Eitchie  found  the  ovum  in  ovarian 
cysts  larger  than  an  ordinary  mature  Graafian  follicle,  which 
proves  that  the  vesicle  need  not  become  obsolete  in  order  to 
degenerate  into  a  cyst ;  and  simple  cysts  of  corresponding  cha- 
racter are  sometimes  met  with  in  the  ovaries  of  new-born  female 
children.  The  mere  presence  of  an  ovum,  however,  is  no  con- 
vincing proof  that  a  follicle  has  not  become  obsolete.  But 
without  excluding  this  as  one  cause  of  the  formation  of  ovarian 
cysts,  others  must  also  be  sought  for  among  the  changing  con- 
ditions of  the  organ.  Probably,  accidental  haemorrhage  into  a 
follicle  approaching  maturity  and  in  its  most  active  stage  of 
formative  power  may  tend  to  morbid  enlargement. 


12  VASCULAR   CONDITION    OF   CYSTS 

Kokitansky  lias  demonstrated  that  cysts  may  be  developed 
from  a  corpus  luteum,  or  from  a  ruptured  follicle  of  which  the 
involution  has  been  arrested.  His  description  of  such  cysts  is 
in  these  words : — '  The  cyst  is  always  lined  with  a  stratum 
thicker  than  the  wall  of  the  follicle  itself,  which  adheres  to  it 
either  very  loosely  by  a  delicate  areolar  tissue,  or  very  inti- 
mately by  a  dense  connective  tissue.  This  lining  stratum  is  of 
a  dirty  white  colour,  and  has  a  rough  inner  surface.  It  may  be 
recognised  as  the  yellow  layer  of  the  corpus  luteum  which  has 
been  rendered  thinner  by  expansion,  and  the  roughness  of  its 
inner  surface  is  occasioned  by  some  of  its  remaining  folds.' 
The  liquefaction  of  the  fibrinous  clot  in  the  corpus  luteum  may 
also  give  rise  to  a  cavity,  which  will  be  found  covered  with 
secreting  cells,  and  may  afterwards  enlarge  so  as  to  have  a 
cystic  form. 

If  hyperemia  is  to  be  taken  into  account  as  operative  in  the 
production  of  cystic  degeneration,  it  must  not  be  forgotten 
that  this  condition  also  occurs  in  the  normal  physiological 
enlargement  of  the  follicle  and  its  final  rupture.  Scanzoni's 
explanation  appears  well  founded,  when  he  points  out  that  a 
thickening  of  the  cell  walls  must  necessarily  take  place  pre- 
viously, if  the  rupture  which  usually  follows  hyperemia  is  to 
be  prevented,  and  the  follicle  degenerate  into  a  cyst.  A  more 
considerable  thickness  of  that  follicular  wall  is,  according  to 
Scanzoni's  view,  either  a  peculiar  malformation  of  the  ovarian 
tissue,  or  the  sequel  of  hypersemia  which  has  caused  abnormal 
deposition  of  the  lining  membrane  of  the  follicle.  Julius  Klob 
frequently  examined  simple  cysts  of  the  ovaries  in  new-born 
children  and  young  girls,  of  which  he  gives  the  following 
account.  In  these  ovaries  there  are  either  cysts  with  homo- 
geneous, serous,  fluid  contents,  or  the  so-called  hsemorrhagic 
cysts — that  is,  follicles  expanded  to  thin  walled  cysts  from 
extravasation  of  blood.  Schultze  found  the  ovarian  stroma  in  a 
child  born  in  breech  presentation  degenerated  to  an  extensive 
network,  completely  filled  with  blood,  both  fluid  and  coagulated, 
and  so  forming  a  simple  cyst.  In  two  cases  mentioned  by 
Klob,  the  capillary  vessels  of  the  follicle  were  atrophied, 
leaving  in  the  one  case  on  the  inner  surface  a  delicate 
tracery,  the  remains  of  the  obliterated  vessels,  and  in  the 
other   stains  of  a  dark  red  or  blackish  colour  from  the   de- 


EXTRA-OVARIAN    CYSTS  13 

composing  blood.  Grohe  advances  an  explanation  of  the 
phenomena.  He  maintains  that  there  are  two  vascular 
systems  in  the  ovary,  independent  of  each  other;  one  set  being 
the  nutritive  vessels  of  the  organ,  the  other  merely  subservient 
to  the  growth  of  the  follicles,  and  ceasing  to  exist  as  they  ripen 
and  burst. 

If  this  be  true,  it  may  be  seen  how  under  certain  conditions 
this  functional,  exclusively  follicular,  set  of  vessels  may  become 
obliterated  after  having  reached  a  given  point  of  development, 
the  generative  life  of  the  follicle  may  cease,  and  its  tissues  fall 
under  the  influence  of  the  simple  nutritive  action  of  the  part, 
which,  by  thickening  the  walls  and  increasing  the  quantity  of 
secreted  fluid  inside,  at  once  converts  the  follicle  into  a  cyst. 
Occasionally,  too,  Graafian  follicles  are  so  deeply  seated  in  the 
structure  of  the  ovary,  that  though  the  ovum  is  fully  formed 
and  ready  for  impregnation,  there  is  no  possibility  of  its  escape 
by  rupture ;  and  its  unwonted  presence  in  such  a  position  may 
give  rise  to  morbid  action.  With  great  local  congestion  there 
is  also  the  possibility  of  intra-follicular  haemorrhage,  and  cysts 
are  found  in  adult  ovaries  distended  in  this  way  to  a  con- 
siderable size.  The  same  thing  on  a  smaller  scale  has  hap- 
pened in  children  and  the  foetus,  and  so  given  the  conditions 
for  cyst  formation.  Besides  this,  the  localized  inflammation  of 
a  single  isolated  follicle  may  be  the  cause  of  cystic  degenera- 
tion. The  true  ovisac  can  often  be  turned  out  from  the  external 
coat  of  the  follicle,  but  a  cyst  once  formed  is  not  to  be  separated 
from  its  attachments  without  dissection. 

SIMPLE   EXTRA-OVARIAN   CYSTS. 

The  annexed  drawing,  from  a  specimen  in  my  possession, 
which  I  removed  from  a  patient  who  had  a  large  cyst  of  the 
opposite  ovary,  shows  remarkably  well  the  character  of  these 
extra-ovarian  cysts,  or  cysts  of  the  broad  ligament. 

The  simple  extra-ovarian  tumours  found  upon  the  broad 
ligament  are  commonly  either  cysts  arising  from  the  tubules 
of  the  parovarium,  or  expansions  of  the  terminal  bulbs  of  the 
Wolffian  organ.  These  vesicular  bodies,  which  are  seen  pendent 
near  the  fimbriated  end  of  the  Fallopian  tube,  or  from  the 
spreading  part  of  the  broad  ligament,  sometimes  fill  with  fluid 


14 


CYSTS    OF    THE    BROAD    LIGAMENT 


till  they  reach  the  size  of  a  nut  or  an  egg.  They  are  described 
in  reports  of  post-mortem  examinations,  made  for  other  pur- 
poses, as  having  thin  walls  covered  with  peritoneum,  no  adhe- 
sions, clear  contents,  and  small  canular  pedicles.  The  thinness 
of  the  walls  and  the  slenderness  of  the  pedicle  will  account  for 
their  often  bursting  or  falling  off  before  giving  any  symptom- 
atic trouble.  But  the  dilatations  of  the  tubules  of  the  parova- 
rium which  have  led  to  the  use  of  the  term  dropsy  of  the  broad 
ligament,  and  which  end  in  the  development  of  true  cysts,  are 
not  at  first  so  strictly  pedunculated,  and  have  an  internal  lining 
of  pale  cylindrical  nucleated  epithelium,  corresponding  with 
that  found  naturally  in  the  tubules.     They  cause  comparatively 


little  constitutional  disturbance,  and  are  not  rapid  in  their 
early  enlargement.  But  by  accidental  production  of  fibrous 
tissue  in  the  coats  of  the  sac,  the  chances  of  bursting  are 
diminished,  and  they  occasionally  grow  to  a  large  size  ;  in  fact, 
some  of  the  very  voluminous  cysts  on  record  were  found  to 
arise  from  some  part  of  the  broad  ligament. 

The  following  is  an  illustrative  case :  A  lady,  aged  twenty, 
had  observed  an  increase  of  size  as  far  back  as  1862,  but  con- 
tinued quite  well  till  three  months  before  I  saw  her  in  August 
1863,  when  the  existence  of  an  ovarian  tumour  had  been  sus- 
pected only  for  a  few  weeks.  The  girth  at  the  umbilical  level 
was  thirty-four  and  a  half  inches,  the  distance  from  the  ensiform 
cartilage  to  the  pubic  symphisis  fifteen  inches,  and  from  the 


*  CYSTS    ON    THE    UTERUS  15 

ilium  to  the  umbilicus  on  the  right  side  nine  inches ;  on  the 
left,  eight.  The  abdomen  was  occupied  with  a  fluctuating 
tumour,  which  extended  upwards  two  or  three  inches  above  the 
umbilicus.  There  was  no  crepitus,  and  no  tenderness  on  pres- 
sure. The  uterus  was  far  backwards,  a  little  to  the  left,  and 
freely  movable;  the  right  side  of  the  vagina  was  depressed, 
giving  rise  to  the  impression  that  the  connection  was  with  the 
right  side  of  the  uterus  and  rather  close.  The  disease  gave  so 
little  uneasiness,  that  all  interference  was  postponed  till  March 
1864,  when  the  increase  had  been  rapid,  from  seventeen  to  nine- 
teen inches  across  the  front  of  the  abdomen,  while  the  vertical 
measurement  still  remained  fifteen  inches.  The  cyst  was  then 
removed  and  the  adjacent  ovary  along  with  it,  as  it  felt  hard 
and  appeared  larger  and  more  corrugated  than  is  usual  in  un- 
married women ;  though,  from  its  being  quite  apart  from  the 
tumour,  it  would  have  been  easy  to  remove  the  cyst  and  leave 
the  ovary.  The  pedicle  was  not  thicker  than  a  finger.  Another 
cyst  the  size  of  a  walnut  in  the  left  broad  ligament  near  the 
ovary  was  laid  open  and  emptied.  Dr.  W.  Fox,  after  exami- 
nation of  the  cyst,  reported  it  as  '  when  distended  about  twice 
the  size  of  an  adult  head.  The  Fallopian  tube  flattened  out  is 
seen  to  course  along  its  external  surface.  The  fimbria?  are 
however,  non-adherent  and  distinct.  The  ovary  is  found  in  a 
fold  of  the  broad  ligament,  distinct  from  the  tumour,  and  pre- 
senting the  natural  appearance.  It  contains  no  cysts.  The 
cyst  itself  has  a  smooth  external  wall.  It  is  lined  internally 
by  a  flattened  polygonal  epithelium.  No  villous  or  papillary 
growths  can  be  discovered  on  its  inner  surface.  This  was  of  a 
delicate  rose  colour.  The  cyst  was  injected  with  carmine  but 
the  arrangement  of  its  vessels  presented  nothing  remarkable. 
The  vascularity  of  the  cyst  was  not  very  great.  No  other  cysts 
could  be  found  in  the  broad  ligament.' 

There  is  another  form  of  extra-ovarian  simple  cyst,  de- 
scribed by  Hugier  under  the  title  of  '  serous  cysts  on  the  ex- 
terior of  the  uterus.'  The  seat  of  their  development  appears 
to  be  the  tissue  connecting  the  peritoneum  to  the  uterus,  and 
for  the  most  part  they  are  found  on  the  back  of  that  organ. 
They  sometimes  grow  as  large  as  an  orange,  but  are  commonly 
of  insignificant  size.  The  attachment  to  the  uterus  is  broad 
compared  with  the  bulk,  but  in  some  cases  the  cyst  elongating 


16  EXTRA-PERITONEAL   CYSTS 

acquires  a  distinct  pedicle,  and  being  freely  mobile,  may  easily 
be  mistaken  for  a  similar  cyst  arising  from  the  broad  ligament 
or  ovary.  They  have  no  specific  characters  indicating  their 
mode  of  origin,  and  are  not  known  to  have  occasioned  more 
than  mechanical  inconvenience.  Extra-peritoneal  cysts  have 
since  been  observed  by  other  writers  in  England  and  Germany. 
They  have  been  found  in  the  lumbar  region  and  other  parts  of 
the  abdomen,  and  no  doubt  many  of  the  non-pedunculated 
tumours  which  have  been  removed  by  enucleation  or  proved  to 
have  such  widespread  attachments  as  to  resist  complete  ex- 
cision and  necessitate  treatment  by  drainage  have  been  cysts 
of  this  kind.  The  important  practical  considerations  which 
this  form  of  growth  gives  rise  to,  and  which  ten  years  ago  we 
had  not  reasoned  out,  will  be  taken  up  when  I  come  to  treat  of 
operative  proceedings  and  the  results  of  incomplete  operations. 
The  fact  that  ova  discharged  from  the  follicle  sometimes 
never  reach  the  uterine  end  of  the  Fallopian  tube,  or,  missing 
it  altogether,  become  aberrant,  and  attach  themselves  to  some 
point  of  the  mucous  or  peritoneal  surface,  where  they  undergo 
changes,  acquire  vascularity,  and  reach  a  certain  size  before 
they  finally  submit  to  extinction,  leads  to  the  supposition  that 
in  particular  cases  the  irregular  development  may  be  prolonged, 
and  there  being  no  generative  impulse,  all  the  nutritive  energy 
may  concentrate  on  the  formation  of  tissue  sufficient  for 
cell  walls  and  the  exudation  of  fluid.  Boinet  writes  thus : 
*  Maintenant,  nous  appuyant  sur  tous  ces  faits,  sur  les  pheno- 
menes  physiologiques  de  l'ovulation  et  de  la  fecondation,  ne 
peut-on  pas  admettre  qu'il  se  passe,  pour  la  formation  des  kystes 
de  l'ovaire,  ce  qui  se  passe  pour  les  vesicules  fecondees  ?  celles- 
ci  se  developpent  quelquefois  dans  l'ovaire  lui-meme,  ou  dans 
la  trompe  de  Fallope,  ou  dans  la  peritoine,  ce  qui  constitue  des 
grossesses  anormales.  Eh  bien,  ne  peut-il  pas  arriver  que 
Povule  non  feconde,  mais  devenu  malade  par  suite  de  toutes 
les  causes  que  nous  venons  d'enumerer  plus  haut,  puisse  se 
developper  pathologiquement  soit  dans  l'ovaire  ou  il  reste  fixe, 
soit  dans  la  trompe  de  Fallope  ou  il  s'est  introduit,  comme  au 
moment  de  la  fecondation,  soit  enfin  dans  la  peritoine,  ou  il 
est  tombe  ? '  Eitchie  also  made  the  same  suggestion  in  his 
book  on  ovarian  pathology,  and  was  supported  by  the  observa- 
tions of  others  on  the  lower  animals. 


*         CASES    OF   TUBO-OVAKIAN    CYSTS 

17 

TUBO-OVAKIAN   CYSTS. 

The  tuboovarian  cysts  have  an  interest  peculiar  to  them- 
selves. They  were  first  described  by  Ad.  Eichard  and  Labbe 
as  Kystes  tubo-ovariennes.  The  case  reported  by  Blasius  in 
1834  as  Hydrops  Ovariorum  profrusus  belongs  to  the  same 
class.  Eokitansky  and  Klob  found  in  several  instances  the 
distended  end  of  the  Fallopian  tube  connected  with  and  open- 
ing into  a  cavity  within  the  ovary.  The  walls  of  the  cysts 
therefore  were  formed  jointly  by  the  tubes  and  the  ovarian 
stroma.  The  ovarian  portion  of  the  cyst  walls  possessed  either 
reticulated  or  smooth,  yellow,  yellowish  red,  or  russet  coloured 
lining  membrane  which  did  not  continue  into  the  tubal  part 
of  the  cyst.  The  distal  third  only  of  the  tube  was  dilated, 
and  the  middle  third  hardly  ever  showed  in  the  formation  of 
the  cyst.  Eichard  only  observed  the  middle  third  to  be  im- 
plicated, in  which  case  the  fluid  of  the  sac  passed  freely  into 
the  uterine  cavity.  But  in  the  case  mentioned  by  Blasius 
there  were  nearly  similar  conditions.  The  junction  of  the 
tubal  end  with  the  rest  of  the  cyst  is  marked  by  a  slight  con- 
striction, or  is  sometimes  indistinct.  In  one  case  Eokitansky 
found  the  cyst  wall  at  that  part  partially  thinner,  as  if  about 
to  sever. 

The  genesis  of  such  cysts  is  explicable.  The  pigmented 
portion  of  the  cyst  wall  represents  the  yellow  layer  of  a  corpus 
luteum.  The  fimbriated  extremity  of  the  Fallopian  tube  had 
been  embracing  that  portion  of  the  ovary  where  the  rupture  of 
a  ripe  Graafian  follicle  was  imminent,  during  a  catamenial 
period.  Instead  of  retracting,  the  fimbriae  remained  adherent 
to  the  ovary,  excessive  secretion  of  fluid  followed,  and  a  cyst 
was  formed.  It  is  curious  that  in  such  cases  the  dilatation 
takes  place  most  rapidly  in  the  ovarian  portion  of  the  cyst, 
though  it  might  have  been  expected  that  the  tubal  walls  would 
have  yielded  more  readily  to  the  pressure  of  the  fluid.  The 
rupture  of  an  ovarian  cyst  previously  formed  in  a  corpus 
luteum  is  a  very  probable  occurrence.  Eichard  has  observed 
two  such  cases,  and  Boinet  has  published  an  account  of  the 
case  of  a  young  married  lady,  which  he  explained  as  the  forma- 
tion of  a  tubo-ovarian  cyst  by  the  bursting  of  a  Graafian 
follicle  into  the  adherent  tube. 

C 


CASES   OF   TUBO-OVARIAN   CYSTS 
18 

Some  years  ago  I  saw  a  lady  in  consultation  with  Mr- 
Arthur,  of  the  Commercial  Eoad.  She  had  a  large  cyst  in  the 
abdomen,  which  we  believed  to  be  ovarian,  and  I  went  one 
day  prepared  to  tap  her,  when  I  found  that  discharge  of  serum 
had  suddenly  come  on  from  the  vagina  some  hours  before,  and 
was  still  continuing,  while  the  abdomen  was  manifestly  dimin- 
ishing in  size.  The  fluid  had  very  much  the  character  of  the 
liquor  amnii,  and,  on  introducing  a  speculum,  Mr.  Arthur  and 
I  both  saw  it  very  distinctly  coming  out  of  the  os  uteri,  and 
along  the  speculum.  The  discharge  continued  for  several 
days,  the  abdomen  regained  its  natural  size,  the  lady  recovered 
good  health,  and  there  has  been  no  reappearance  of  the  cyst, 
which  was  assuredly  one  made  up  by  the  union  of  the  tube 
with  an  ovarian  cavity. 

A  case  which  occurred  in  the  practice  of  Mr.  Anderson,  of 
York  Place,  furnished  ocular  demonstration  of  this  tubo- 
ovarian  form  of  tumour.  A  woman  with  symptoms  so  urgent 
as  to  require  tapping  sent,  on  the  day  fixed  for  the  operation, 
to  say  that  she  was  passing  such  a  quantity  of  urine  that  all 
her  distress  had  vanished.  At  the  visit  it  was  found  that  the 
discharge  still  continued.  It  proved  to  be,  as  Mr.  Anderson 
writes,  '  simply  highly  albumenised  serum,  with  cholesterine 
plates.  The  case  went  on,  the  woman's  size  lessening  till  she 
gained  flesh  again.  After  some  six  months  she  died  from  a 
sudden  outburst  of  hsemoptysis.  On  post-mortem  examination, 
a  large  empty  cyst,  with  thick  walls,  and  including  some  lesser 
cysts,  was  found  lying  collapsed  and  loose  in  the  belly.  The 
cyst  on  being  slit  open,  where  the  escape  had  taken  place, 
became  immediately  obvious,  and  a  good-sized  staff  (No.  10  or 
11)  passed  with  the  greatest  facility  along  one  of  the  Fallopian 
tubes  into  the  uterus  and  vagina.  The  parts  were  sent  to  the 
College  of  Surgeons,  and  now  lie  hidden  and  undiscoverable 
among  the  mass  of  accumulated  specimens.' 

The  following  case  of  tubo-ovarian  cysts  recorded  by  Dr.  L. 
Beale  in  the  '  Pathological  Transactions '  for  1867-8  is  curious  : 
The  patient,  a  married  woman,  aged  thirty,  died  under  Dr. 
Beale's  care  in  King's  College  Hospital  of  chronic  renal  disease. 
For  the  last  year  of  her  life  she  had  not  menstruated ;  there 
was  no  history  of  any  uterine  affection ;  and  she  had  never  been 
pregnant.    After  death  two  tumours  were  found  in  the  pelvis,  one 


MULTIPLE    OVARIAN    CYSTS  19 

on  each  side  of  the  uterus ;  the  left  one  was  circular,  about  the 
size  of  a  small  orange,  and  distended  with  fluid ;  on  its  upper 
and  inner  surface  was  seen  a  tortuous  but  not  uniformly  dilated 
canal,  which  was  closed  at  the  uterine  end,  but  opened  freely 
into  the  larger  cyst  at  its  ovarian  extremity ;  this  was  the 
uterine  portion  of  the  Fallopian  tube,  while  the  cyst  was  the 
dilated  fimbriated  extremity.  The  tumour  on  the  right  side 
was  smaller,  and  the  inner  portion  of  the  tube  was  uniformly 
dilated  into  a  canal,  one-third  of  an  inch  in  diameter;  like  the 
one  on  the  other  side,  it  communicated  with  the  cyst  by  a 
smooth  circular  opening. 

On  each  side  the  inner  constriction  was  just  outside  the 
uterus,  where  the  tubes  seemed  to  be  merely  fibrous  cords ; 
externally  the  fimbriated  extremites  were  also  closed  and  dilated 
into  roundish  cysts.  Each  cyst  had  thin  walls  with  fluid  con- 
tents of  a  dark-brown  colour.  The  left  ovary  could  not  be  seen  ; 
the  right  ovary  was  flattened  out  and  lying  in  the  wall  of  the 
cyst,  but  not  communicating  with  it.  No  traces  of  ovarian 
structure  were  left,  but  a  mere  cyst  with  semifluid  contents  of 
a  chocolate  colour. 

The  uterus  was  quite  normal  in  appearance ;  but  no  distinct 
opening  could  be  seen  at  the  fundus,  where  the  tubes  generally 
enter ;  outside,  the  peritoneal  surface  was  normal,  nor  were 
there  any  adhesions  showing  previous  inflammation. 

MULTIPLE   OVARIAN   CYSTS. 

Every  tissue  and  organ,  however  healthy,  has  a  propen- 
sity, under  given  stimulation,  to  an  abnormal  reproduction 
of  itself.  There  are  tumours  of  every  form  of  tissue,  modi- 
fied by  the  various  conditions  of  nutrition;  and  outgrowths 
of  compound  gland  structure  are  equally  common  produc- 
tions. The  ovary,  instead  of  being  an  exception  to  the  rule, 
is  perhaps  one  of  the  greatest  transgressors  in  this  respect. 
Some  physiological  perversion  occurs  in  the  natural  career  of  a 
Graafian  follicle  ;  it  fails  in  the  evolution  of  an  ovum,  but  it 
succeeds  as  a  monster  cell-growth,  and  becomes  a  simple 
unilocular  ovarian  cyst,  the  simplest  form  of  adenoid  tumour. 
Two  or  more  Graafian  follicles  do  the  same  thing  simultaneously ; 
they    abort,   grow  side   by   side,   fill  with   fluid,   become   an 

c  2 


20 


GROWTH   OF   MULTIPLE   CYSTS 


enormous  assemblage  of  similar  units,  disfiguring  and  stimu- 
lating each  other  by  pressure  and  reflex  action,  forming 
preternatural  adhesions  within  and  without,  and  at  length,  by 
their  very  excess  of  development,  inducing  in  their  component 
tissues  the  inevitable  process  of  involution,  and  in  the  organized 
being  to  which  they  belong  a  lingering  decay  and  death.  In 
this  is  recognizable  an  adenoid  tumour  of  the  true  type  and 
tendency,  aggressive  and  destructive,  though  not  essentially 
malignant.  Graining  a  certain  size,  however,  it  generally 
happens  that  one  out  of  the.  many  dropsical  follicles  takes  the 
lead  of  the  rest.  Annihilating  some  of  its  neighbours,  it  dwarfs 
others,  lessens  their  vitality,  vitiates  their  contents,  and  fills 


more  rapidly  than  they.  And  this  struggle  for  existence  seldom 
goes  on  long  without  destroying  their  integrity ;  pressure  and 
expansion  cause  obstruction  to  the  circulation  in  the  cell  walls. 
Atrophy  and  absorption  are  the  natural  consequences,  and  the 
boundaries  being  wholly  or  partially  gone,  or  represented  only 
by  bands  or  bridges  of  membrane,  the  adjacent  cells  communi- 
cate, and  the  tumour  assumes  what  is  called  the  multilocular 
form.  This  process  of  excavation  may  even  go  further,  till  all 
the  cavities  become  continuous,  or,  with  a  total  clearance  of 
every  partition,  the  cyst  remains  only  one-chambered.  The 
tumour  here  represented  was  peculiar  in  that  the  trabecule 
were  very  fine,  and  the  vesicles  they  enclosed  for  the  most  part 


FOEMATION   OF   CYSTS  21 

retained  their  globular  or  oval  form,  had  clear  contents,  and 
were  translucent.  The  case  was  reported  by  Dr.  Eitchie,  and, 
as  he  expressed  it,  the  tumour  '  might  be  looked  upon  as  a 
normal  ovary  dissected  by  hydrotomy.'  These  transforma- 
tions cannot  be  called  capricious,  but  they  are  unaccount- 
able, since  they  are  found  taking  place  at  an  early  period 
in  some  small  tumours,  while  others  of  large  size  preserve 
their  multiple  vesicular  character  intact.  The  elementary 
tissues  of  these  composite  cell  walls  are  much  the  same  as  those 
constituting  the  unilocular  cysts,  but  the  nature  of  the  contents 
of  the  several  loculi  varies  almost  indefinitely.  Liquidity,  con- 
sistence, colour,  and  chemical  composition  may  be  different 
throughout.  One  cell  may  contain  nearly  solid  matter;  the 
next  a  limpid  fluid  ;  in  one  may  be  pus,  in  another  serum  with- 
out any  trace  of  cell  formation ;  there  is  union  in  the  mass, 
but  no  uniformity  of  action  in  the  parts,  and  the  growth  having 
overstepped  the  bounds  of  healthy  influences  comes  to  ultimate 
destruction  by  the  irregular  play  of  a  series  of  morbid  changes. 

Undoubtedly,  too,  there  are  cysts  formed  in  the  ovary  as  in 
other  organs,  quite  independently  of  the  advanced  Graafian 
follicles.  Bursse  are  soon  produced '  under  the  skin  by  mere 
friction ;  and  the  accidental  presence  of  any  foreign  body  such 
as  crystallised  matter  or  exuded  fluid  in  a  tissue,  or  the  stimu- 
lation of  some  immaterial  irritant,  may  cause  the  formation  of 
cyst  walls.  And,  once  organised,  they  are  capable  of  rapid 
augmentation  of  volume  or  multiplication.  There  are  often 
discovered,  in  examinations  of  the  ovary,  cysts  which  bear  no 
relation  to  Graafian  follicles  or  corpora  lutea,  but  which  seem 
to  have  originated  in  the  deep  areolar  tissue,  or  among  the 
vessels  of  the  gland.  They  may  have  commenced  as  tiny 
deposits  of  fluid  in  some  one  of  the  areolar  spaces,  about  which 
condensation  of  the  surrounding  tissue  would  soon  take  place, 
with  the  speedy  production  of  a  limiting  capsular  membrane, 
channelled  out  with  capillary  vessels ;  or  it  is  allowable  to 
retreat  a  step  further  for  explanation,  and  fall  back  upon  the 
easily  roused  innate  power  of  evolution  of  the  plastic  nuclei 
and  cells  of  the  tissue. 

Leopold  of  Leipsic  has  a  paper  in  the  number  for  August, 
1881,  of  Virchow's  'Archives,'  on  the  transplantation  of  em- 
bryonic tissues,  in  which  he  relates  experiments  proving  that 


22  PROLIFEROUS   CYSTS 

the  result  is  sometimes  that  of  a  growth  which  may  fairly  be 
called  a  tumour.  But  all  that  he  has  done  and  recorded  fails 
to  support  the  hypothesis  recently  put  forward  by  Cohnheim, 
that  all  tumours,  ovarian  as  well  as  others,  owe  their  being  to 
the  persistence  in  various  organs  and  parts  of  the  body  of  small 
residues  of  embryonic  tissue.  There  is  a  great  difference  be- 
tween a  visible  graft  which  you  have  yourself  cut  from  a  foetus, 
or  a  wandering  ovum  which  you  can  trace,  and  an  invisible 
residue  of  tissue  which  has  never  been  demonstrated — that 
is,  between  a  fact  and  a  possibility  ;  and,  as  it  appears  to  me, 
the  presence  of  embryonic  tissues  in  tumours,  when  we  look 
at  the  conditions  in  which  they  exist,  goes  to  show  not  so  much 
the  point  of  origin  as  the  degenerative  tendency  and  lethal 
destiny  of  such  growths. 

PROLIFEROUS    CYSTS. 

An  ovarian  adenoid  proliferous  tumour  is  a  parent  cyst 
filled  with  its  progeny  of  endogenous  cysts,  or  surrounded  by 
others  of  exogenous  growth.  It  may  have  the  same  origin 
as  other  cysts,  and  its  early  condition  would  be  that  of  a 
common  unilocular  cyst.  In  fact,  any  epitheliated  cysts  may 
become  proliferous,  and  they  are  found  in  all  parts  of  the 
body.  But  wherever  they  are,  they  have,  when  filled  up,  the 
same  complex  appearance  to  a  casual  observer  and  seem  equally 
to  defy  description  or  comprehension.  When  cut  open,  the 
interior  is  seen  to  be  choked  up  with  other  cysts,  growing  from 
all  sides,  crowding  and  pressing  each  other  out  of  shape.  From 
the  outside  of  these  secondary  cysts  others  grow,  and  the  same 
outgrowth  may  be  again  repeated  upon  them.  So,  too,  if  these 
inner  cysts  are  opened,  another  endogenous  series  may  be  dis- 
closed within,  and  the  budding  does  not  necessarily  stop  there. 

Want  of  space  and  failing  vitality  only,  either  in  the  patient 
or  the  part,  put  an  end  to  the  process.  A  through  section 
gives  to  view  a  space  circumscribed  by  the  cyst  wall,  irregularly 
areolated,  with  the  membranous  septa  impinging  upon  each 
other  at  every  conceivable  angle,  and  pourtraying  the  out- 
lines of  the  interspaces  and  loculi.  The  thickness  of  the 
walls  generally  keeps  pace  with  the  growth  of  the  cysts,  the 
little  ones  looking  only  like  distended  bladders;  but  a  small 


PEOLIFEEOUS    CYSTS 


23 


additional  growth  yields  fibrous  tissue,  with  vessels  entering 
the  pedicle  and  ramifying  everywhere.  The  internal  surface 
has  epithelium,  and  often  looks  flocculent  when  the  layer  is 
not  very  fine. 

But  proliferous  cysts  have  degrees  of  fertility.  Some  breed 
to  suicidal  repletion ;  others  fill  with  fluid  and  nourish  a  few 
clusters,  or  only  a  single  symmetrical  cluster  of  secondary  cells, 
which  have  room  enough  and  to  spare,  and  hang  pendent  in 
the  cavity.  Now  and  then  only  one  solitary  bud  indicates  the 
self-multiplying  tendency  of  the  parent  cyst. 

It  is  in  these  simple  cases  that  the  mode  of  development  can 
be  studied,  and  here  is  revealed  the  clue  to  the  problem.  The 
Graafian  follicle  is  a  proliferous  cell.  It  is  lined  with  epithe- 
lium. In  course  of  time,  one  of  these  cells,  a  sort  of  queen 
cell,  probably  the   developed   nucleus   of  the   cell   originally 


formed  in  the  couche  ovigene,  makes  a  fresh  start  in  life,  in- 
creases in  size,  fills  out  to  roundness,  and  feeds  its  own  nucleus 
till  it  becomes  conspicuous  as  the  germinal  vesicle.  This  again 
reproduces  its  like  within  itself,  the  germinal  spot,  another  cell. 
At  this  point  this  triply  involved  cell  awaits  the  spermatic 
influence  to  deviate  into  a  new  career  and  to  commence  the 
generation  of  a  new  set  of  cells  by  division,  endowed  with 
the  novel  formative  properties  necessary  for  the  building  up  of 
tissues  the  same  as  those  of  the  being  from  which  it  sprang. 
But  this  fecundating  influence  not  arriving,  it  falls  the  prey  of 
involution,  softens,  dwindles  away,  and  melts  down  out  of  sight 
among  the  rest  of  the  ejecta.  This  is  what  happens  in  the 
healthy  Graafian  follicle.  But  suppose  the  Graafian  follicle  is 
injured,  or  some  morbific  influence  taints  it,  and  the  ovum  is 
blasted,  the  vesicle  then  takes  on  a  cystic  form  and  enlarges. 


24 


PROLIFEROUS   CYSTS 


It  is  still  lined  with  epithelium,  and  that  shares  with  the  rest 
of  the  structure  the  evil  impression.  Some  individual  cells 
distinguish  themselves  by  eccentric  shapings ;  they  elongate, 
form  a  pedicle,  and  show  their  nuclei.  After  a  time  they 
throw  out  a  pouch -like  projection,  which  lengthens,  grows  as  it 
were  on  a  stem,  and  is  nucleated  too.  Groups  of  cells  some- 
times act  together  in  the  same  way.  Or  it  may  be  that  a 
cell  becomes  columnar,  or  ramifies,  and  assumes  dendritic 
forms,  budding  after   a   like   fashion.     In   the   case   of  their 


having  plenty  of  space  and  abundant  nutriment,  they  elaborate 
a  fibrous  coat  with  capillary  vessels,  push  on  symmetrically, 
and  hang  into  the  cavity  like  a  close  set  bunch  of  currants. 

Intensify  the  growing  power  sufficiently,  and  a  proliferous 
cyst  is  soon  filled  with  progeny,  and  presents  the  complicated 
aspect  first  described.  But,  as  all  these  secondary  growths  throw 
out  successive  generations  of  epithelium  on  both  their  surfaces 
equally  with  the  parent  cyst  walls,  the  cells  lying  upon  them 
are  liable  to,  and  do  undergo  the  same  changes  and  develop- 


OVA    IN    GRAAFIAN    FOLLICLES    OF   CYSTS  25 

ments  as  the  cysts  they  crop  out  of.  Two  modes  of  the  in- 
crease of  the  tumour  are  thus  evident — the  reproduction  of  new- 
cells  with  cystic  tendencies,  and  repeated  gemmation  from  the 
newly  formed  cells  and  cysts. 

Yet  another  complication  of  these  proliferous  cysts  presents 
itself.  Some  parts  of  the  cell  walls  have  in  them  the  same 
plastic  elements  which  form  the  couche  ovigene  of  Sappey,  and 
these  may  be  roused  into  activity.  They  grow,  and  grow  as 
they  were  designed  to  grow,  into  Graafian  follicles,  containing 
ova.  The  demonstration  of  this,  as  a  fact,  was  first  made  by 
Eokitansky,  who  published  his  discovery  in  the  year  1855  in 
the  'Wochenblatt  der  Zeitschrift  der  KK.  Gresellschaft  der 
Aerzte  zu  Wien,'  where  he  describes  the  appearances  observed 
in  a  woman,  twenty-six  years  of  age,  who  died  of  diseased 
ovaries.  Both  ovaries  were  affected.  The  tumour  on  the  right 
side  was  as  large  as  a  child's  head,  that  on  the  left  as  large  as  a 
man's  fist.  Both  ovaries  were  composed  of  a  number  of  cysts 
as  large  as  a  cherry,  which,  for  the  most  part,  lay  closely  packed 
together,  here  and  there  became  flattened  by  mutual  compres- 
sion, and  occasionally  were  projected  into  each  other.  The 
surface  of  the  tumours  was  thus  slightly  lobulated,  and  between 
the  protuberances  were  seen,  at  intervals,  cysts  as  large  as  a 
barley-corn,  a  pea,  or  a  bean.  These  latter  cysts  on  being 
punctured  gave  exit  to  a  greenish- coloured  fluid,  containing 
membranous  flocculi,  and  in  all  of  them  the  ovum  was  found. 
In  each  of  them,  however,  the  ovum  was  softened,  very  dull- 
coloured,  and  easily  disintegrated.  The  zona  pellucida  had  for 
the  most  part  lost  its  sharp  contour,  and,  except  in  one  case,  no 
germinal  vesicle  was  discoverable. 

Subsequently,  in  the  year  1864,  the  late  Dr.  Charles  Eitchie 
had  the  opportunity  of  seeing  the  same  thing  demonstrated  in 
the  ovaries  of  a  married  woman,  fifty-four  years  of  age,  who  was 
sent  to  me  in  December  1863  by  Dr.  Whitehead  of  Man- 
chester, on  account  of  ovarian  disease.  She  was  admitted  to 
the  Samaritan  Hospital  late  in  May  1864,  and  ovariotomy 
was  performed  on  June  2.  The  pedicle  of  a  non-adherent 
tumour,  larger  than  an  adult's  head,  on  the  right  side,  was 
secured  by  a  clamp  about  three  inches  from  the  uterus,  and 
the  cyst  cut  away.  A  second  cyst,  nearly  as  large  as  the  first, 
u;i~  then  found  on  the  left  side,  which  was  also  tapped  and 


26  RITCHIE   ON    OVA   IN   CYSTS 

emptied.  The  pedicle  of  this  second  cyst  was  transfixed,  tied 
with  strong  silk  in  two  halves,  and  secured  to  the  clamp  on 
the  other  pedicle  after  the  cyst  was  cut  away.  Eecovery  was 
uninterrupted,  except  by  a  superficial  abscess,  which  formed 
beside  the  lower  angle  of  the  wound. 

The  two  tumours  were  examined  directly  after  their  removal 
by  Dr.  Eitchie,  who  pointed  out  to  me  in  each  of  them  a 
number  of  small  cysts,  which  were  evidently  enlarged  Graafian 
follicles.  Knowing  the  great  and  long  familiarity  which  Dr. 
Woodham  Webb  has  had  with  the  ova  of  various  species  of 
animals,  since  his  researches  in  conjunction  with  Barry,  I  asked 
him  to  examine  some  of  the  cysts,  in  order-to  ascertain  whether 
they  did  or  did  not  contain  ova — aware  that  upon  this  point 
no  higher  authority  could  be  appealed  to.  As  one  friend  had 
suggested  that  we  may  have  mistaken  a  blood  corpuscle  (!)  for 
an  ovum,  there  was  evidently  some  reason  for  my  caution ;  but 
I  trust  that  the  following  note  from  Dr.  Webb  will  set  all  such 
doubts  at  rest : — 

'  Both  the  tumours  you  sent  me,  after  their  removal  from 
a  woman  fifty-four  years  old,  were  growths  in  excess  of  true 
ovarian  structure.  The  multilocular  character  was  produced 
by  clusters  of  ovisacs  of  various  sizes.  Ova,  with  the  other 
natural  contents,  were  to  be  found  in  all  the  small  sacs.  The 
fibrous  coats  of  the  larger  sacs  were  thickened,  and  had  many 
secondary  sacs  developed  in  them.  The  interior  was  lined 
with  epithelium,  which  in  some  instances  had,  by  parthe- 
nogenetic  enlargement  and  successive  buddings  of  the  cells, 
given  rise  to  bunches  of  grape-like  growths — repeated  gene- 
rations of  imperfect  ova.  The  whole,  therefore,  was  nothing 
more  than  a  reproduction  in  the  human  subject  of  conditions 
which  are  natural  in  some  of  the  lower  creatures.' 

As  this  discovery  is  of  importance  in  the  history  of  ovarian 
pathology,  I  add  a  letter  from  Dr.  Kitchie,  which  was  published 
in  the  'Medical  Times  and  Gazette,'  August  6,  1864.  He 
says  :  *  Before  and  since  the  particular  observation  referred  to, 
I  have  been  struck  with  the  probability  of  many  so-called  ova- 
rian cysts  being  actually  due  to  degeneration  of  the  ovum  itself. 
In  one  ovarian  tumour,  which,  through  Mr.  Wells's  kindness,  I 
had  an  opportunity  of  examining,  I  found  a  number  of  thin- 
walled  bladders,  varying  from  the  size  of  a  cherry  to  that  of  a 


EITCHIE   ON  CYSTS  27 

large  plum.  These  bladders  were  easily  enucleated  from  the 
fibrous  stroma  which  surrounded  them,  and  there  could  be  no 
reasonable  doubt  that  they  were  Graafian  follicles  somewhat 
distended  by  over-secretion.  The  interior  of  these  cysts  was 
searched  in  vain  for  the  ovum,  but  I  was  much  struck  with  the 
fact  that  in  the  great  majority  of  them  the  cyst  wall  was  thick- 
ened at  one  point,  and  at  one  only,  and  that  on  making  a  section 
through  that  point  a  small  secondary  cyst  was  discovered.  No 
doubt  it  will  be  said  that  at  this  point  endogenous  growth  had 
commenced,  but  it  is  a  significant  fact  that  there  was  only  one 
such  growth  to  each  follicle,  and  that  it  lay  imbedded  in  a 
thickening  of  its  inner  coat.  What  can  be  more  probable  than 
that  it  was  the  ovum  lying  imbedded  in  its  cumulus  proligerus  ? 
We  know  that  every  ovum,  whether  it  be  fertilised  or  not, 
undergoes  certain  definite  changes  on  arriving  at  maturity.  .  . 
.  .  Those  changes  have,  as  far  as  I  am  aware,  as  yet  only  been 
observed  while  the  ovum  was  contained  in  the  Fallopian  tube ; 
but  it  certainly  is  perfectly  conceivable  that  in  those  cases 
where  ripe  follicles  fail  to  burst,  the  matured  ovum  should 
undergo  its  wonted  metamorphosis  while  still  contained  in  its 
ovisac.  Nor  is  it  absurd  to  suppose  that  under  those  altered 
circumstances  the  progressive  dilatation  of  the  blastodermic 
vesicles  should  occasionally  exceed  its  normal  limit,  and  go  on 
to  the  formation  of  a  cyst  which,  in  structure  and  position, 
would  exactly  correspond  to  the  little  secondary  cavity  which 
was  seen  in  the  wall  of  the  enlarged  Graafian  follicle. 

*  I  cannot  think,  however,  that  the  ovum  always  stops  short 
at  this  early  stage  of  its  development.  Its  constant  tendency 
is  towards  the  formation  of  a  new  animal,  but  when  deprived 
of  the  stimulus  of  the  spermatozoon,  it  constantly  falls  short 
of  its  aim.  Perhaps  it  may  go  on  to  the  production  of  what, 
were  it  found  in  the  uterus,  would  be  styled  a  grape-mole  ; 
perhaps  other  forms  of  cystic  degeneration  may  be  more 
frequent.' 

In  Dr.  Eitchie's  work  on'  Ovarian  Physiology  and  Pathology,' 
published  1865,  the  following  passage  appears,  p.  197.  It  shows 
that  he  perseveringly  continued  his  researches,  and  that  his 
industry  was  not  then  less  rewarded  than  there  is  every  reason 
to  hope  it  would  have  been  in  other  ways,  had  his  career  not 
been  stayed  by  death  just  as  he  had  gained  the  impetus  of 


28  WILSON    FOX    ON   OVARIAN   CYSTS 

success.  '  Since  last  August,  1864,  I  have  succeeded  in  find- 
ing ova  in  some  of  the  loculi  of  a  large  number  of  ovarian  cysts. 
Some  of  the  ova  were  perfect,  with  a  sharply  defined  zona  pel- 
lucida,  a  germinal  vesicle  and  a  germinal  spot ;  others  were 
more  or  less  imperfect,  many  having  the  appearances  mentioned 
by  Kokitansky.  I  have  never  found  an  ovum  in  a  loculus  larger 
than  a  cherry,  and  never  in  a  loculus  which  contained  jelly- 
like contents.' 

Among  the  many  pathologists  who  have  investigated  this 
difficult  subject,  one  of  the  earliest  and  most  masterly  is  Dr. 
Wilson  Fox,  whose  trustworthy  observations  deserve  special 
notice.  In  a  communication  to  the  Medico-Chirurgical  Society, 
read  June  1864,  he  has  expressed  an  opinion  that  all  the  forms 
of  cysts  met  with  in  the  ovary  originate  from  the  Graafian 
follicles,  and  that  the  multilocular  forms  are  not  the  result  of 
any  special  degenerations  of  the  stroma  of  the  ovary,  but  are 
due  to  secondary  formations  from  the  interior  of  parent  cysts. 
He  has  studied  the  modes  of  formation  of  the  secondary  cysts 
thus  formed,  and  has  divided  them  into  three  classes. 

The  first  and  most  frequent  manner  in  which  secondary 
cysts  are  formed  (occurring  in  ten  out  of  fifteen  specimens)  is 
the  result  of  the  production  of  a  series  of  granular  structures, 
presenting  a  tubular  type,  on  the  inner  wall  of  the  parent  cyst. 
Dr.  Fox  describes  the  mode  of  formation  of  these  glands  as 
differing  from  those  of  other  glands,  which  for  the  most  part 
originate   in  the   embryo  as  diverticula   from    surfaces.     The 

t  process  in  this  case  commences  with  a  strati- 
fication of  the  epithelium,  into  which  project 
papillae  formed  of  the  stroma  of  the  wall  of  the 
parent  cyst,  each  papilla  carrying  a  delicate 
vascular  loop.  Villi  more  or  less  densely 
clustered  are  thus  formed,  which  may  persist 
^^  as  such,  and  then,  according  to  Drs.  Wilks, 
Tubular      glands  Friedreich,  and  Luschka,  may  become  covered 

FrTstooma6110108^  ^^  ciliated  epithelium ;  but  in  a  large  number 
of  cases  they  become  converted  into  tubular 
structures  by  the  upward  growth  of  the  stroma  around  their 
bases.  Cysts  may  be  formed  while  they  are  thus  situated 
on  the  surface,  from  the  occlusion  of  their  orifices  by  mutual 
pressure ;  but  most  commonly  the  growth  of  the  stroma,  by 


ADENOMA  29 

which  this  tubular  character  was  first  determined,  continues 
until  they  are  completely  imbedded  in  the  wall  and  covered 
by  a  fresh  layer  of  the  stroma,  the  surface  of  which  may 
again  become  the  seat  of  a  new  and  similar  growth  of  glands 
and  villi.  Masses  of  glands  thus  imbedded  are  dilated  into 
cysts  by  their  own  secretion,  and  form  the  small  semi-solid 
masses  which  project  into  the  interior  of  the  parent  cysts,  and 
in  them  similar  processes  may  be  repeated  indefinitely.     In 


Cysts  and  Compound  Masses  of  Glands,  which  are  capable  of  expand- 
ing into  Loculated  Cysts,  imbedded  in  wall  of  Parent  Cyst. 
(  x  150  Diam.  reduced.) 

October  1862  I  exhibited  at  the  Pathological  Society  a  tumour 
which  I  described  as  adenoma  of  the  ovary,  adding  that  it 
might  be  called  nbro-epithelioma  or  alveolar  adenoid  tumour. 
The  report  in  the  '  Transactions,'  vol.  xiv.  p.  205,  runs  thus  : 
'  Mr.  Wells  had  not  seen  a  similar  growth  in  the  ovary  before, 
nor  had  he  found  it  described  by  any  author.  A  drawing  of 
Dr.  Hughes  Bennett's,  of  the  structure  of  chronic  mammary 
tumour,  might  have  been  taken  from  one  of  the  sections  shown 
to  the  Society.  It  consisted  in  great  part  of  an  ordinary 
multilocular  cyst ;  but  one  large  cyst  was  filled  with  semi-solid 
matter  which  at  first  sight  looked  exactly  like  soft  cancer ;  but 
after  hardening  in  spirit  the  true  character  was  made  out,  and 
it  was  seen  that  the  surface  of  the  growth  was  fringed  with 
papilliform  villi,  its  substance  showing  in  vertical  sections  a 
delicate  fibrous  stroma  forming  round  or  oval  alveoli.  These 
alveoli  are  lined  with  densely  grouped  epithelial  cells,  forming 
a  continuous  zone  which  encloses  an  area  loosely  packed  with 
cellular  elements  of  similar  form.  On  the  margins  of  most 
sections  the  contents  of  the  alveoli  are  frequently  seen  to  pro- 


30 


WILSON   FOX    ON   OVARIAN   CYSTS 


trude  like  papillae  through  ruptured  portions  of  the  fibrous 
septa ;  or  the  lining  zone  of  the  alveolus  has  become  liberated 
and  divided  so  as  to  assume  the  appearance  of  a  long  cylin- 
drical band  or  column  of  epithelial  cells.  The  tumour  there- 
fore belongs  distinctly  to  the  class  of  fibro- epithelial  growths, 
and  from  the  folliculoid  character  of  its  alveoli  would  be  most 
appropriately  classed  as  adenoma.'  This  condition  has  been 
described  by  Eokitanski  as  occurring  in  one  case  which  came 
under  his  observation,  and  was  published  in  the  Vienna  '  Journal 
of  the  Society  of  Physiology,  I860.' 

For  the  more  minute  description  of  the  changes  above 
mentioned  I  must  refer  the  reader  to  Dr.  Fox's  paper.      In 

three  out  of  the  fifteen  cases  he 
has  examined,  where  multilocular 
cysts  existed,  and  in  which  he 
could  not  find  the  glands  last 
described,  Dr.  Fox  met  with  a 
process  of  secondary  cyst  forma- 
tion of  a  somewhat  different  cha- 
racter. The  cysts  in  these  cases 
gave  off  diverticula,  which  pro- 
ceeded both  from  the  thin-walled 
varieties  and  from  those  situated 
in  the  denser  portions  of  the 
stroma.  In  the  former  case  the 
diverticula  (which  resembled 
those  in  which  many  glandular 
structures  originate  in  the  embryo  from  the  gastro-pulmon- 
ary  canal)  expanded  at  once  into  cysts  which  projected  into 
the  interior  of  similar  adjacent  formations ;  while  in  the 
latter,  long  tubular  follicles  were  given  off,  portions  of  which 
became,  by  a  series  of  successive  constrictions,  converted  into 
cysts. 

The  third  class  of  cases  investigated  by  Dr.  Fox  were  those 
where  cysts  are  found  associated  with  cauliflower  growths 
springing  from  the  interior  of  the  parent  cysts.  This  class,  to 
which  the  theory  of  the  origin  of  cysts  from  single  cells  has 
been  chiefly  applied  by  Eokitansky,  has  received  a  different 
explanation  from  Dr.  Fox.  He  describes  these  growths  as  solid 
masses,  consisting  of  a  very  vascular  prolongation  of  the  stroma 


Three  Diverticular,  or  Secondary 
Cysts,  projecting  through  the 
outer  wall  of  a  Thin-walled 
Cyst,  from  a  Multilocular  Ova- 
rian Tumour.  (  x  90  Diam.  re- 
duced.) 


WILSON    FOX    ON    OVARIAN   CYSTS 


31 


of  the  ovary  covered  by  epithelium,  and  from  the  surfaces  of 
which  may  spring  an  indefinite  number  of  similar  growths.     In 
these  luxuriant  growths  spaces  covered  by  epithelium  become 
enclosed,  and,  inasmuch  as 
the  epithelium  forms  a  se- 
creting surface,  these  shut 
spaces   become    dilated    to 
cysts.     Numerous  instances 
of  this  process  are  given  in 
Dr.  Fox's  paper. 

Dr.  Fox  has  appended 
to  his  paper  some  analysis 
of  the  fluids  contained  in 
these  cysts,  from  which,  in 
conjunction  with  those  of 
Dr.  Owen  Eees  and  Scherer, 
he  concludes  that  their  con- 
tents are  not  due  to  any 
degeneration  of  the  stroma 
of  the  ovary,  but  that  their 
varying  reactions  are  owing 
to  the  conditions  of  pressure  Formation  of  Secondary  Cysts,  by  Tubular 
Under   which  the    fluids  are       Jesses  given  off  from  Cysts  in  thicker 

portions  of  Stroma.    (  x  250  Diam.  re- 
secreted    from    the    lining      duced.) 

membrane  of  the  cysts. 

Having  thus,  in  all  the  so-called  '  colloid  cysts  '  examined 
by  him,  traced  the  formation  of  secondary  cysts  to  newly  formed 
structures  of  a  glandular  type  (Dr.  Fox  believes  that  those 
found  in  conjunction  with  the  cauliflower  growths  must  be 
placed  in  the  same  category,  '  as  they  can  only  be  regarded, 
similarly  to  the  Haversian  fringes  of  synovial  membranes,  as 
everted  glandular  structures '),  he  calls  attention  to  the  obser- 
vations of  Pfliiger  and  Billroth  on  the  origin  of  the  Graafian 
follicles  from  tubular  processes  in  the  early  embryonic  con- 
ditions of  the  ovary,  an  opinion  which  his  own  observation  leads 
him  to  confirm,  and  he  expresses  his  belief  that  the  origin  of 
all  the  varieties  of  these  cystoid  tumours  must  be  traced  to  '  a 
renewal  in  the  adult  of  the  early  mode  of  development  of  the 
Graafian  vesicle ;  with  various  morbid  aberrations  from  the  type 
of  embryonic  growth,  a  morbid  condition  of  which  we  already 


32  HARRIS  AND  DORAN  ON  OVARIAN  CYSTS 

possess  instances  in  the  mamma,  the  testicle,  and  the  thyroid 
gland.' 

Dr.  Fox  believes,  though  he  has  not  had  any  opportunities 
^-*niv      «-  „  of   examining    multilocular 

cysts  containing  dermic 
structures,  '  that  these  will 
be  found  to  follow  the  same 
law,'  'inasmuch  as  they 
have  been  shown  to  con- 
tain both  normal  hair  folli- 
cles, sebaceous  and  sudori- 
parous glands,  all  of  which 
structures  are  the  frequent 
seat  of  cyst  formation.' 

Very    recently,    in    the 

'  Journal    of  Anatomy  and 

Physiology '  for  July  1881, 

^Xnrv^       Messrs.   Harris   and   Alban 

Doran  published  an  account 

Vertical  Section  through  a  Cauliflower  Mass,  of  their  studies  of  the  cystic 

showing  the  mode  of  formation  of  Cysts  ;  disease  of  the  ovaries  in  the 

irregular  spaces  lined  by  Epithelium  en- 

closed  by  Papillary  Growths.     ( x  250  earlier  stages.      They   had 
Diam.  reduced.)  the  opportunity  of  procur- 

er. Spaces  at  base  of  growth.  jng     manv      twin      ovaries, 

b.     Space  at  apex,  entirely  enclosed.         ■•  .  -,  ,      .    . , 

0  f,        ,      z  which  were  removed  at  the 

ce.  Spaces  partly  enclosed. 

same  time,  and  in  all  the 
cases  the  large  tumour  was  multilocular.  It  was  to  the 
second  ovaries  corresponding  to  these  multilocular  tumours 
that  they  confined  their  attention,  and  '  all  were  so  distinctly 
enlarged  and  so  abnormal  in  appearance  as  to  afford  the 
strongest  presumptive  evidence  that  they  were  in  a  state  of 
incipient  cystic  degeneration.'  Their  observations  have  evi- 
dently been  carefully  made,  and  they  have  described  and 
figured  the  histological  changes  during  some  of  the  stages 
of  the  involution  of  the  follicle.  I  add  a  summary  of  their 
conclusions  which  confirm  much  that  was  either  indicated 
or  stated  in  somewhat  different  language  in  my  first  edition. 
The  varicose  origin  of  some  ovarian  tumours  is  not  disputed, 
and  '  the  partial  dilatation  and  partial  obstruction  of  enlarged 
and  thickened  blood-vessels '  is  part  and  parcel  of  such  con- 


CONCLUSIONS    OF    HARRIS   AND    DORAN  33 

dition ;  while  the  follicular  origin  of  many  tumours  has  long 
been  an  admitted  fact.  But  no  one  has  before  worked  satisfac- 
torily upon  the  early  stages  of  the  degenerative  changes  which 
render  these  tumours  so  serious  independently  of  their  mere 
increase  of  size  ;  and  there  is  no  doubt  that  the  same  zeal  and 
intelligence  which  has  brought  them  thus  far  will  in  due  time 
give  results  enabling  us  to  fill  up  some  of  the  blanks  in  this 
meagre  chapter  of  pathology. 

The  conclusions  of  Harris  and  Doran  are  stated  in  these 
terms : 

'  1 .  There  is  strong  evidence  that  multilocular  cystic  disease 
of  the  ovary  may  arise  from  two  totally  different  ovarian 
elements. 

'  2.  Cysts  may  arise  from  partial  dilatation  and  partial 
obstruction  of  enlarged  and  thickened  blood-vessels. 

'  3.  Cysts  more  frequently  appear  to  originate  in  changes  in 
those  Graafian  follicles  that  undergo  involution  without  having 
ever  ruptured. 

'  4.  The  morbid  changes  which  replace  normal  involution  of 
the  follicle  are  an  active  ingrowth  from  the  stroma,  and  a  long 
persistence  of  the  cloudy  tube-like  bodies  that  represent  the 
remains  of  the  membrana  propria  of  the  follicle.  These  two 
processes  sometimes  proceed  at  an  equal  rate,  sometimes  irre- 
gularly. 

'  5.  When  the  relics  of  the  membrana  propria  are  slow  to 
disappear,  and  the  stroma  slowly  sends  ingrowths  amongst 
these  relics,  we  find  the  cystic  bodies  containing  myxoma-cells 
partly,  at  least,  connected  with  the  ingrowths. 

'  6.  When  the  process  of  ingrowth  of  stroma  into  the  fol- 
licle, during  involution,  is  particularly  active,  the  ingrowths 
interlace  and  rapidly  form  cystic  spaces,  including  portions  of 
the  cloudy  relics  of  the  membrana  propria. 

1  7.  On  the  other  hand,  the  stroma  may  show  little  or  no 
tendency  to  develop  ingrowths,  but  the  relics  of  the  membrana 
propria  may  break  down  very  slowly,  and  end,  not  in  simple 
effacement  and  incorporation  with  the  stroma,  but  in  slowly 
breaking  down.  This  must  necessarily  end  in  the  formation  of 
a  cyst  full  of  a  colloid  or  semi-fluid  material,  the  completely 
broken  down  granulosa.  In  all  cases  of  myxomatous  or  colloid 
changes,  or  simple  rarefaction  of  tissue,  we  found  full  evidence 


34  CYSTS    IN    FCETAL    OVARY 

that  those  changes  were  in  degenerate  follicles  and  never  free 
in  the  stroma. 

'  8.  All  these  changes  in  the  degenerating  membrana  propria 
and  the  tissue  surrounding  the  follicle  begin  as  exaggerations 
of  the  normal  process  of  involution,  which  is  never  a  mere  dis- 
integration and  degeneration  of  the  follicle. 

'  9.  These  changes  in  the  follicle  do  not  appear  due  to 
inflammation. 

'  10.  The  manner  in  which  the  young  cyst  first  becomes 
invested  with  its  characteristic  epithelium  is  obscure.  .  .  . 
As  long  as  the  source  whence  normal  epithelium  is  renewed 
remains  obscure,  so  long  must  this  question  remain  unsettled.' 
Still  more  recently  Mr.  Doran  has  been  examining  the 
ovaries  of  a  foetus  of  seven  months,  and  in  one  he  found  prolife- 
rating cysts,  the  origin  of  which  he  traces  back  to  the  vestigial 


m 


remains  of  some  of  the  tubes  of  the  Wolffian  bodies.  Two  of 
these  cysts  are  seen  in  the  wood-cut  as  magnified  by  a  two-inch 
objective.  The  right-hand  cyst  measures  y^in.  in  its  long- 
diameter  and  has  epithelial  tufts  projecting  from  its  walls. 
Between  the  two  larger  cysts  are  a  number  of  small  cystic  or 
tubular  bodies  which  under  a  higher  power  are  seen  to  be 
lined  with  epithelium  similar  to  that  which  invests  the  growth 
in  the  two  bigger  ones.  Stroma  continuous  with  that  of  the 
ovary  exists  in  the  tufts  but  cannot  be  represented.  The  ovary 
contained  no  Graafian  vesicles,  though  they  were  abundant  in 
that  of  the  other  side. 


NEW    FORMATIONS    IN    OVARIAN    CYSTS  35 


DERMOID    CYSTS. 

Another  form  of  proliferous  cyst  is  that  which  is  known  by 
the  name  of  dermoid.  Here  the  development  does  go  on  to  a 
higher  point.  The  accidental  new  formations  in  ovarian  cysts, 
though  not  so  common  as  the  fluid  contents,  occur  often  enough 
to  make  them  not  only  objects  of  curiosity  but  of  pathological 
importance.  Among  these  substances  may  be  mentioned 
striated  muscular  fibres,  brain  and  nerve  tissue,  bone,  adipose 
tissue,  and  all  sorts  of  dermoid  structures — such  as  hair,  teeth, 
and  glands.  As  a  rule,  the  growth  of  cysts  of  this  kind  is 
arrested  after  a  certain  time ;  they  remain  stationary ;  and  if 
the  abdomen  of  the  patient  goes  on  enlarging,  it  is  generally 
owing  to  the  outpouring  of  ascitic  fluid  from  the  irritation 
to  which  the  cysts  give  rise.  Sometimes  inflammation  and 
suppurative  action  set  in,  and  the  contents  are  discharged  by 
apertures  communicating  with  the  natural  passages,  or  through 
fistulous  openings  in  the  abdominal  walls. 

The  new  formation  of  striated  muscular  fibres  has  been 
observed  by  Virchow,  who  gives  the  following  description. 
The  accumulated  stroma  in  a  large  ovarian  tumour  formed 
prominences  in  different  parts  of  the  cyst  walls,  and  between 
the  cysts  a  large  quantity  of  dense  tissue  was  found  as  a  fibril- 
lated,  whitish  mass,  in  which  were  imbedded  nodules  of  various 
sizes — from  that  of  a  cherry  to  that  of  a  large  apple — and  of  a 
yellowish  white  colour.  There  were  a  few  among  them  which 
had  an  almost  glandular  appearance;  they  were  delicately 
mottled  with  yellow,  and  were  firm,  but  not  hard.  They 
nowhere  presented  a  distinctly  fibrillated  or  fascicular  arrange- 
ment. But,  under  the  microscope,  dense  layers  of  striated 
muscular  fibres  were  seen,  having  the  same  form  and  general 
characters  as  those  of  the  embryo.  The  single  fibres  were  long, 
moderately  broad,  fusiform  cells,  with  a  long  oval  nucleus, 
and  well-marked  transverse  striation.  Virchow  suggests  for 
tumours  containing  such  tissue  the  name  of  Myosarcoma. 

Brain  matter,  as  seen  in  these  cysts,  has  been  described 
by  Gray,  Chalice,  Friedreichs,  and  Eokitansky.  Gray  found  a 
tumour  the  size  of  an  orange,  consisting  of  five  cysts.  Three 
of  these  contained  fat  and  hair;  one  of  them  also  bones  and 


36  NERVE  MATTER  IN  DERMOID  TUMOURS 

one  tooth.  The  fourth  cavity  was  the  size  of  a  walnut,  had 
very  thin  walls  resembling  the  pia  mater,  forming  like  that  a 
sort  of  meshwork,  and  it  inclosed  a  brain-like  mass,  in  which 
the  elements  of  the  gray  substance  and  nerve  fibres  were 
discernible.  The  fifth  and  smallest  cyst  had  similar  contents, 
Chalice  discovered  a  soft,  white  and  grayish  substance,  resem- 
bling brain,  in  the  ovarian  cyst  of  a  young  girl.  And  Eoki- 
tansky  met  with  an  independent  nervous  apparatus,  arising  from 
a  ganglion,  in  a  cylindrical  osseous  new  formation,  covered 
with  true  cutis,  growing  into  an  ovarian  cyst.  The  mass  was 
also  vascular.  The  reddish  ganglionic  substance  was  enveloped 
in  a  caj)sule  formed  by  two  layers  of  the  cell  wall.  A  nervous 
cord  issued  from  the  ganglion,  and  sent  ramifications  into  the 
osseous  body,  which  were  ultimately  distributed  in  the  same 
way  as  the  nerve  fibrils  of  the  cutis. 

Friedreichs  examined   an  ovarian   cyst  of  the  size  of  an 
apple,  consisting  of  two  cavities.     A  conical  mass  of  cuticular 
structure  was  attached  to  the  uterine  end  of  the  larger  cavity, 
and  projected   into   it.     This   body  was  covered   with   hairs, 
contained  adipose  tissue,  complete  and  rudimentary  sebaceous 
glands,  and  distinct  nerve  fibres,  with  double  dark   borders. 
Numerous  recently  formed  vessels,  and  thirty  strong  cords  of 
broad  nervous  branches,  with  double  borders,  were  found  in 
the  areolar  tissue  of  the  expanded  membranous  septum.     On 
the  opposite  surface  of  the  septum,  forming  part  of  the  smaller 
cyst,  tnere  were  thick  whitish  layers,  of  very  soft  consistency, 
which   were    made   up    of  innumerable   thin,    varicose    nerve 
fibres,  with   well-defined  borders,   and   all   having   the   same 
direction    and    parallel   arrangement.      Between   these    were 
interspersed  irregularly  thicker  nervous  elements,  with   double 
borders.      There   were   also   large    unipolar  and   bipolar  pig- 
mented ganglionic  cells,  with  large  round  nuclei.     A  delicate 
capillary  network  pervaded  with  its  large  meshes  the  whole 
new-formed  medullary  substances,  and  was  kept  together  by 
a  fine  but  perfect  investing  membrane.      The  nuclei  of  the 
connective  tissues  in  this  were  partly  pigmented,  and  partly  in 
a  state  of  fatty   degeneration.     At  two  points  in  the  white 
medullary   nerve   substance    there  were    seen   extremely  soft, 
almost  pulpy,  grayish,  transparent  masses,  which  consisted  of 
nerve  cells,  with  circular  nuclei  (gray  substance).      These  were 


TEGUMENTARY    CONTENTS    OF    DERMOID    TUMOURS  37 

also  supplied  with  small  capillary  vessels.     Virchow  has  seen  a 
similar  case. 

Genuine  dermoid  cysts  occur  most  commonly  in  the  ovaries, 
although  not  exclusively  so,  as  they  are  sometimes  attached  to 
the  peritoneum,  and  may  be  developed  in  other  parts  of  the 
body.  Of  one  hundred  and  eighty-eight  instances  of  dermoid 
cysts  which  Lebert  reports,  one  hundred  and  twenty-nine  were 
in  the  ovaries.  In  my  own  experience  the  greater  part  were 
ovarian.  Nor  are  they  peculiar  to  the  female  sex.  They  occur 
in  man  and  in  the  males  of  other  species. 

The  ovarian  dermoid  cysts  may  be  either  single  or  multiple, 
and  several  of  the  cysts  in  a  multiple   tumour   may   contain 
similar  structures.     The  cyst  walls  are  mostly  thick ;  the  inner 
surface  may   be    uniformly  smooth,  but  more  often  is    made 
uneven  by  being  scattered  over  with  circumscribed  elevations, 
some  of  which  may  even  rise  into  conical  hillocks.     The  lining 
membrane  is  composed  of  thick  layers  of  pavement  epithelium. 
The  uppermost  strata  of  cells  are  scaly  and  without  nuclei ; 
those  beneath  show   the   nuclei,  and   the    deepest- seated   are 
round  cells  newly  formed;  the  same  arrangement  as  in  the 
epidermis.     This    cuticular   layer    is    often    more    than    two 
millimetres  thick,  and  rests  on  a  bed  of  areolar  tissue,  which, 
like  the  cutis,  is  furnished  with  papilla?  of  the  usual    forms. 
Although  these  papillae  are  as  closely  packed  together  as  on 
the  palm  of  the  hand  and  fingers,  they  are  not  arranged  in 
parallel   rows    or   regular   groups,    and   are    different    in    size 
and  length.     Next  to   the   papillary   layer   comes    a  mass  of 
looser  areolar  and  adipose  tissue.     In  this  sort  of  mock   skin 
the  usual  tegumentary  appendages  are  often  developed  in  con- 
siderable quantities.     Abundant  tufts  of  hair  are  thrown  out, 
sometimes    several  inches  in   length,  more  commonly  fair  or 
of  reddish  colour  than  brown  or  black.     The  hairs  grow  from 
distinct  follicles,  with  which  sebaceous  glands  are  connected. 
Other  sebaceous  glands  open  directly  on  the  surface  of  the  cyst. 
Kohlrausch,   Heschl,  and    others  have    also  remarked  sudori- 
parous glands  with  very  much  their  natural  form  and  disposi- 
tion.    Wedl  mentions,   in  respect  to  the  hair,  that  notwith- 
standing its  considerable  length,  it  more  resembles  in  general 
structure  the  short  hair  of  the  body  than  that  of  the  scalp. 
The  follicles  do  not  lie  so  deep,  and  the  bulbs  are  more  conical 


38  BONE    IN    DERMOID    TUMOURS 

and  elongated.     The  bone  developed  in  these  cysts  shows  itself 
first  as  minute  laminae  in  the  areolar  tissue  beneath  the  skin 
formation.     These,  as  they  grow  larger,  get  into  most  extra- 
ordinary irregular  shapes,  with  branches  and  spicules,  or  into 
lumps,  composed  more    of  dense  compact  substance  than   of 
porous  spongy  tissue.     The  pieces  sometimes  have  a  distant 
resemblance  to  some  parts  of  the  skull,  and  this  is  more  striking 
when  teeth,  as  they  very  often  do,  grow  in  regularly  formed 
alveoli,  such  as  are  seen  naturally  in  the  jaws.     The  osseous 
structure  itself  is  that  of  genuine  bone,  the  Haversian  canals 
and  bone  cells  being  arranged  in  lamellae,  though  the  cells  are 
often  large,  and  have  fewer  intercommunicating  branches.     In 
some  instances,  pieces  of  bone  are  held  together  by  a  sort  of 
spurious  articulation,  formed  by  the  periosteum  and  some  dense 
fibrous  tissue.     Such  a  case  is  recorded  by  Heschl.     The  teeth 
develop  either  in  the  osseous  substance  or  in  the  cyst  stroma. 
They  sometimes  project  into  the   cyst,  or  may  be  completely 
buried  in  the  areolar  tissue.     Some  are  perfect,  and  have  all 
the  structural  arrangement  of  ordinary  teeth,  but  the  greater 
part  remain  in  a  rudimentary  condition.     According  to  Meckel, 
they  observe   the   same   natural   order   of  succession,   and   a 
deciduous  tooth  will  be  seen  atrophied  from  root  to  crown  by 
the  pressure  of  a  permanent  tooth  growing  under  it.     So  it 
was  in  one  of  the  tumours  removed  by  me  in  operation  (Case 
329).     But  a  great  many  of  the  teeth  are  badly  formed,  and 
have  certain  parts  deficient  or  in  excess.     The  number  in  a 
single  cyst  is  sometimes  extraordinary.     Schabel  describes  the 
case  of  a  girl,  aged  thirteen,  not  having  menstruated,  and  in 
whom  there  was  an  ovarian  cyst,  three  times  the  size  of  a  man's 
head,  containing  three  pieces  of  bone  and  more  than  a  hundred 
teeth  of  all  classes,  but  mostly  incomplete,  without  proper  roots. 
Paget  mentions  a  cyst  in  which  more  than  three  hundred  teeth 
were  found. 

Besides  the  adipose  tissue  forming  part  of  the  organised 
mass  in  these  tumours,  the  sacs  often  contain  a  large  quantity 
of  greasy  substance,  mixed  up  with  tufts  and  balls  of  matted 
hair.  This  consists  of  free  fat,  exfoliated  epithelium,  with 
sometimes  so  much  cholesterine  that  the  crystals  give  the 
whole  a  glittering  appearance.  With  a  surface  of  skin  and 
sebaceous  glands,  there  is  no  difficulty  in  accounting  for  the 


DOCTRINE    OF   CONTINUOUS    DEVELOPMENT  39 

presence  of  these  concretions.  Eokitansky  found  this  fatty 
compound  in  one  case  rolled  into  a  number  of  round  balls. 
The  cyst,  the  size  of  a  large  head,  had  contracted  adhesions 
below  with  the  ovarian  ligament,  and  above  with  the  anterior 
layer  of  the  middle  portion  of  the  mesentery  of  the  jejunum. 
Thus  balanced,  the  cyst  was  twice  rotated  on  its  axis  from  left 
to  right.  It  contained  a  quantity  of  brownish,  viscid  fluid, 
numerous  balls  of  matted  hair,  as  large  as  a  walnut,  seventy- 
two  balls  the  same  size,  made  up  of  fat  in  concentric  layers, 
and  a  great  number  of  smaller  globules,  not  bigger  than  peas. 
Fatal  constriction  of  the  intestines  had  been  the  result  of  the 
rotations  of  the  tumour,  and  Eokitansky  accounts  for  the 
peculiar  condition  of  the  contents  by  the  churning  motion. 
Dr.  Routh  found  the  fat  and  hair  in  a  cyst  which  he  removed 
from  an  old  woman  in  much  the  same  state.  The  balls  had 
concentric  layers  of  amorphous  fat  round  a  nucleus  of  choles- 
terine  crystal. 

The  question  whether  these  dermoid  cysts  are  the  result 
of  impregnation  (direct  or  secondary)  does  not  need  discussion. 
They  have  a  character  quite  distinct  from  that  of  extra- 
uterine foetations,  and  grow,  independently  of  spermatic  con- 
tact, in  young  children,  and  even  before  birth,  and  in  situations 
and  under  conditions  where  such  influence  would  be  simply 
impossible.  The  peculiar  formative  and  reproductive  power 
inherent  in  the  tissues  of  the  body  is  as  operative  in  the  pro- 
duction of  these  vagaries  as  it  is  in  the  crops  of  multiform 
morbid  growths  which  spring  up  everywhere  under  circum- 
stances of  which  we  can  give  no  rational  explanation. 

The  doctrine  of  the  '  continuous  development  of  tissues  out 
of  one  another,'  as  Virchow  calls  it,  will  suffice  to  account  for 
the  growth  of  all  ordinary  dermoid  tumours,  no  matter  in  what 
part  or  sex  they  are  found.  Those  of  the  abdomen,  whether  in 
males  or  in  females,  whether  in  the  ovary  itself  or  out  of  it, 
whether  the  solid  dermoid  structures  are  the  original  basis  of 
the  tumour  or  whether  they  are  secondary  productions  from 
the  cyst  substance,  are  no  exceptions. 

But  the  tumours  formed  as  the  result  of  direct  impregnation 
are  of  quite  another  character.  Extra-uterine  fetation  may 
take  place  in  the  ovary,  or  in  the  Fallopian  tube,  or  on  the 
peritoneum,  but   so   long   as   the   embryonic  development  is 


40  FORMATIVE   POWER 

natural,  it  has  no  analogy  with  the  hetero-plastic  mass  of  the 
dermoid.  They  are  not  morbid  products  to  be  classed  among 
diseases  of  the  ovary  ;  and  though  in  their  early  stages  the  fact 
of  enlargement  may  raise  the  question  of  cystic  formation,  the 
further  growth  brings  with  it  the  solution,  and  the  patient 
either  dies  of  haemorrhage  or  has  to  submit  to  abdominal 
section,  or  carries  a  lithopedion  to  her  grave.  With  a  deviation 
from  typical  conformation,  an  arrest  or  perversion  of  nutrition 
and  degradation,  the  product  falls  into  the  category  of  tumour, 
but  still,  instead  of  becoming  a  dermoid  excrescence,  it  remains 
an  embryonic  evolution. 

Neither  need  we  go  beyond  this  simple  doctrine  to  range 
in  their  proper  place  the  anomalous  cases  of  what  are  called 
'  monstrosities  by  inclusion,'  or  '  kystes  foetaux  par  inclusion.' 
It  is  as  superfluous  to  call  in  the  hypothesis  of  Boinet  of  double 
impregnation  and  foetal  inclusion,  or  that  of  a  partial  displace- 
ment of  the  outer  layer  of  the  blasto-dermic  membrane,  or  the 
roundabout  suggestion  of  Lebert  of  the  primary  generation  of 
skin  from  the  elements  of  the  part  invaded,  and  its  secondary 
throwing  out  of  structures  and  organs,  to  explain  these  forma- 
tions, as  it  is  to  insist  upon  the  embryonic  origin  of  every 
dermoid  tumour. 

In  my  own  experience  the  larger  number  of  dermoid 
tumours  were  distinctly  ovarian,  but,  like  other  operators,  I  have 
sometimes  found  them  without  pedicle,  and  dependent  upon 
their  parietal  or  omental  adhesions  for  the  supply  of  blood. 
They  occasionally,  after  acquiring  a  certain  growth,  remain 
quiescent  for  many  years.  Atlee  describes  the  post-mortem 
examination  of  a  lady  who  died  at  the  age  of  seventy-nine,  in 
whom  the  tumour  was  recognized  by  his  uncle  forty-seven  years 
before.     In  this  case  there  was  no  pedicle. 

The  dermoid  tumours  are  usually  spoken  of  as  rare.  Peaslee 
vaguely  says  they  are  found  in  the  proportion  of  1^  or  2  per 
cent.  I  met  with  ten  among  my  first  five  hundred  cases,  and 
twelve  in  the  second  five  hundred,  but  patches  or  nodules  of 
the  growths  in  question  are  not  unfrequently  discovered  in 
the  walls  of  cysts,  which,  from  the  predominance  of  other 
characteristics,  are  not  ranked  in  this  class.  In  fact,  as  a  sub- 
division of  the  proliferous  cysts,  the  dermoid  has  no  definite 
limits,  and  the  gradations  from  the  encysted  foetus,  however 


IN    OVARIAN    CYSTS  41 

monstrous,  through  all  the  varieties  of  hard  and  soft  tissues 
may  be  regularly  traced  down  to  the  simple  hypertrophy 
of  the  connective  tissue  of  the  ovary,  or  the  part  in  which 
the  growth  originated.  It  is  only  a  question  of  the  force  of 
formative  power.  In  ordinary  cases  it  goes  no  further  than 
the  production  of  cyst  walls  with  a  secreting  endothelium, 
which  pours  out  fluid  contents.  In  others,  though  the  cell 
growth  is  enormous,  there  is  no  disposition  to  organization; 
the  vitality  is  low,  and  all  the  phenomena  of  degradation  show 
themselves  in  the  form  of  proliferous  excrescences,  cancerous 
and  colloid  masses. 

Again,  when  Graafian  vesicles  sprout  up  in  the  cyst  walls 
there  is  mostly  an  arrest  of  development,  and  nothing  more 
than  secondary  cysts  are  produced.  Where  the  formative 
impulse  is  stronger,  some  of  the  connective  tissue  and  fibre 
of  the  cell  wall  assumes  the  muscular  type ;  other  of  the 
embryonic  tissue  cells  advance  in  the  direction  of  cartilage 
and  bone,  and  with  a  still  more  exaggerated  impulse  the 
developmental  action  approaches  so  nearly  to  that  which  is 
natural  that  complicated  organs  and  entities,  monstrous,  it  is 
true,  reflect  the  form  of  the  species  in  which  they  take  their 
origin.  They  were  in  times  past  looked  upon  as  inexplicable 
marvels,  and  not  only  had  their  entry  into  museums  as  trea- 
sures, but  were  described  with  scrupulous  verbosity.  There  is, 
however,  nothing  more  extraordinary  in  them  than  in  the  ap- 
pearance of  bone  in  the  gluteus,  or  imperfect  brain-like  matter 
in  the  substance  of  the  mammary  gland,  or  fibrous  nodules  in 
the  lobes  of  the  cerebrum.  Their  chief  surgical  interest  is  in 
the  obscurity  they  throw  over  diagnosis,  and  in  the  complica- 
tions they  occasion. 

I  formerly  gave  the  descriptive  details  of  ten  cases.  The 
first  and  second  had  no  special  peculiarities.  The  third  was  an 
Irishwoman,  married,  27  years  of  age,  and  mother  of  four 
children,  who  recovered  very  speedily  and  gave  birth  to  another 
child  nine  months  after  the  operation.  The  fourth  was  a  single 
lady,  and  in  her  case  the  tumour  consisted  of  three  distinct  por- 
tions, as  shown  in  the  diagram  (next  page)  :  the  ovary,  the  der- 
moid growth,  and  a  large  cyst  with  fluid.  The  greater  part  of 
the  hard,  fibrous,  almost  cartilaginous  walls  of  the  dermoid  cyst, 
which  was  the  size  of  an  orange,  was  ossified,  as  indicated  by 


42 


CASES    OF 


the  shading  in  the  diagram.  The  bony  portion  was  a  flat 
expansion  nearly  surrounding  the  cavity ;  and  from  the  inner 
side  of  it  there  was  a  thick  solid  mass  of  bone  projecting,  which 
had  very  much  the  shape  of  the  lower  jaw  of  a  rodent  (less 
the  coronoid  process),  and  set  with  badly  shaped  teeth.  The 
fifth  and  sixth  patients  were  married  women  aged  37  and  22. 
The  seventh  was  a  girl  of  18,  who  had  been  menstruating  only 
six  months,  was  one  of  twins,  and  had  noticed  the  growth  of  the 
tumour  for  four  years.  In  the  next  patient,  38  years  old,  the 
tumour  had  been  growing  for  eighteen  years.  She  had  married 
during  that  time  and  had  three  children,  the  tumour  lessening 
with  the  progress  of  each  pregnancy.     There  was  no  pedicle, 


the  blood  supply  having  been  kept  up  through  the  vessels  of 
adhering  omentum  and  mesentery.  She  was  pregnant  at  the 
time  of  operation,  and  was  delivered  of  a  living  child  seven 
months  after.  The  ninth  patient  was  barely  17  years  of  age, 
with  a  tumour  of  three  years'  date,  and  a  long  pedicle  three 
times  twisted  on  itself.  All  these  cases  did  well.  The  tenth 
case  came  into  hospital  too  late  for  operation.  Tapping  brought 
away  some  pints  of  turbid  yellow  fluid  with  lumps  of  fat. 

In  1874  I  operated  on  a  little  girl  from  California,  eight 
years  old.  The  case  is  not  unique,  but  is  worth  recording. 
The  child  was  rather  small  for  her  age,  and  the  central  part 
of  the  abdomen  was  occupied  by  a  loose,  movable  cyst.  After 
consultation  with  Sir  W.  Jenner  and  Dr.  Sutro,  I  tapped  with 
a  fine  trocar  and  aspirator,  and  obtained  twenty-six  ounces  of 
ovarian  fluid.  A  hard  substance  like  half  an  orange  was  felt  to 
the  left  side  after  the  fluid  had  all  escaped.  The  child  did  not 
suffer  at  all  after  the  tapping,  but  the  fluid  soon  began  to  dis- 
tend the  cyst  again,  so  that  at  the  end  of  about  three  weeks  I 


DERMOID    TUMOURS  43 

operated  for  extirpation.  I  made  an  incision  of  three  inches, 
drew  out  the  cyst,  tied  a  long  pedicle,  and  the  knots  of  the 
ligature  were  allowed  to  fall  back  into  the  pelvis.  On  examin- 
ing the  uterus  and  other  ovary  with  one  finger,  I  was  doubtful 
which  ovary  I  had  removed,  though  I  believed  it  was  the  left. 
The  uterus  did  not  feel  as  large  as  a  walnut,  and  I  could  not 
find  an  ovary  nor  the  ligature  I  had  just  applied.  The  tumour 
was  dermoid,  but  had  nothing  extraordinary  among  its  con- 
tents, and  is  preserved  in  the  Museum  of  the  College  of  Sur- 
geons. The  child  recovered  perfectly,  and  sailed  for  New  York 
twenty-five  days  after  the  operation.  I  heard  from  Dr.  Cole, 
of  St.  Francisco,  who  was  present  during  the  Congress  in 
London,  August  1881,  that  she  remains  in  good  health. 

This  year  I  saw  a  very  similar  case  in  a  young  lady  aged 
13,  from  Boston,  U.S.  Sir  James  Paget  and  Mr.  Thornton 
had  both  discouraged  operative  measures,  fearing  that  the 
growth  was  malignant.  An  exploratory  puncture  threw  no  light 
on  the  matter,  and  on  my  strong  recommendation  it  was  arranged 
that  Mr.  Thornton  should  remove  the  tumour,  as  I  fully  believed 
it  to  be  a  dermoid  cyst  of  one  ovary.  Sir  James  Paget  and  I 
were  both  present  at  the  operation,  which  Mr.  Thornton  per- 
formed without  difficulty  and  with  a  successful  result,  disclosing, 
as  I  anticipated,  a  dermoid  growth. 

The  bones  and  teeth  of  many  of  these  tumours  have  been 
beautifully  prepared  for  me  by  Dr.  Junker  by  a  process  of  his 
own  devising.  After  removing  most  of  the  surrounding  soft 
structures,  he  scalds  the  harder  parts  with  boiling  water  to  which 
a  few  drops  of  hydrochloric  acid  have  been  added.  The  bones 
are  left  in  this  solution  about  ten  minutes,  then  washed  and 
boiled  in  plain  water  until  all  the  soft  matter  is  loosened. 
This  is  cleared  away  by  a  stream  of  water.  The  bare  bones  are 
then  boiled  a  short  time  in  a  strong  solution  of  soda,  washed 
with  soap  and  water,  and,  when  perfectly  clean,  dehydrated  in 
boiling  alcohol.  These  specimens  may  be  seen  in  the  Museum 
of  the  College  of  Surgeons. 

CYSTOSARCOMA. 

In  most  of  the  tumours  hitherto  mentioned,  the  cystic 
cavities   have   been    the    most    noticeable    features.       Rut    it 


44  CYSTOSARCOMA 

sometimes  happens  that,  though  a  number  of  cysts  exist 
together,  the  cavities  are  in  a  measure  obliterated  and  their 
presence  obscured  by  the  hyperplastic  condition  of  their  walls. 
These  overgrown  partitions  are  made  up  of  a  fibrous  vascular 
mass  not  in  any  way  to  be  distinguished  from  that  usually  seen 
in  cyst  walls.  Its  excessive  quantity  is  its  only  peculiarity,  and 
by  its  encroachments  on  all  sides  the  area  of  the  cysts  and  the 
amount  of  their  contents  are  proportionally  diminished.  Some 
authors  have  given  to  this  form  of  the  disease  the  name  of 
cystosarcoma.  The  solidity  or  softness  of  these  tumours  will 
of  course  depend  on  the  relative  growth  of  the  walls,  or  the 
expansion  of  the  cysts.  It  is  not  at  all  uncommon  to  find  them 
in  connection  with  large  cysts  developing  perhaps  in  some  part 
of  the  walls,  or  more  commonly  towards  the  base.  In  some 
cases,  the  whole  ovary,  having  given  rise  to  one  or  more  large 
cysts,  increases  after  this  fashion.  It  grows  very  rapidly,  and 
has  a  strong  hemorrhagic  disposition,  causing  also  in  some 
cases  effusion  of  blood  into  the  cyst  cavities. 

In  Case  No.  Ill,  the  fluid  of  the  first  tapping  was  trans- 
parent and  straw-coloured  ;  of  the  second  thicker,  of  a  light 
port  wine  tint;  of  the  third,  six  or  seven  weeks  later,  after 
a  good  deal  of  emaciation,  of  a  dark  brownish-red  colour,  con- 
taining a  large  quantity  of  blood.  During  the  operation  several 
large  masses  of  clot  and  fibrin  were  turned  out  of  the  cyst. 
Dr.  Eitchie  reported  of  the  cyst  that  the  thickness  of  the  walls 
was  increased  at  intervals,  the  increase  being  most  marked 
at  one  point  where  the  sensation  given  to  the  finger  was  that 
of  the  presence  of  a  fibrous  tumour  in  the  walls  of  the  cyst. 
This  tumour  was  eight  inches  long,  six  inches  broad,  and  from 
one  and  a  half  to  two  and  a  half  inches  deep.  It  consisted  of 
ovarian  tissue,  many  of  the  meshes  being  filled  with  lardaceous 
deposit,  some  loculi  undergoing  fatty  degeneration,  and  others 
becoming  purulent.  In  the  loculi  nearest  the  large  sac  the 
internal  wall  had  given  way,  and  the  contained  clot  projected 
like  a  fungoid  mass,  which  was  easily  broken  down  with  the 
finger,  and  resolved  itself  into  shreds  and  granules.  The  lining 
membrane  of  this  part  of  the  large  cyst  had  a  mucoid  appear- 
ance, and  was  excessively  vascular.  Large  veins  ran  in  every 
direction,  and  several  of  the  largest  of  them  were  more  or  less 
corroded.     Some  of  the  corrosions  did  not  extend  through  all 


CASES   OF    CYSTOSARCOMA 


45 


the  coats  of  the  vessels,  and  these  appeared  under  a  magnifier 
as  small  ulcers  with  ragged  edges.  Where  the  ulcer  had 
eaten  through  and  through  the  vessel,  blood  had  been  effused 
and  a  clot  formed.  The  accompanying  engraving  represents 
some  of  the  vessels. 


In  another  case,  No.  96,  Dr.  Eitchie  found  the  cyst  walls 
in  some  places  two  inches  thick.  In  this  part  '  were  developed 
between  the  two  internal  layers,  and  intimately  connected  with 
them  both,  a  mass  of  cysts  varying  from  the  size  of  a  pear  to 
that  of  a  pea,  the  larger  ones  being  compressed  laterally,  the 
smaller  ones  retaining  the  spherical  form.  The  extremities  of 
the  ellipses  formed  by  the  larger  among  these  bladder-like 
vesicles  projected  into  the  principal  cavity,  whose  walls  formed 
crescentic  margins  around  them.' 

The  solid  matter  of  the  tumour  removed  in  Case  No.  97  con- 
sisted of  honey-combed  masses,  whose  cells  contained  a  thick, 
white,  semi-solid  substance,  of  the  consistence  of  tallow.  The 
greater  part  of  the  tumour  reported  on  by  Dr.  Eitchie,  in  Case 
No.  99,  was  made  up  of  a  resistant  mass  of  about  the  size  and 
shape  of  an  ordinary  placenta.  '  On  making  a  section  through 
this  it  was  found  to  be  invested  on  every  side  by  a  firm 
fibrous  capsule,  about  two  lines  in  thickness.  This  capsule 
sent  projections  into  the  interior  of  the  tumour,  and  these 
projections  met  and  crossed  each  other  at  different  angles,  so 
as  to  form  a  network.  From  the  interstices  of  the  network 
projected  a  number  of  thin-walled   translucent  vesicles,  con- 


46 


CASES   OF   CYSTOSARCOMA 


taining  a  colourless  fluid.  The  largest  of  them  did  not  exceed 
the  size  of  a  small  plum,  while  the  smallest  were  mere  specks. 
Most  of  the  larger  ones  had  been  forced  into  an  elongated  oval 
shape,  and  as  they  projected  from  the  fibrous  network,  the 
latter  formed  a  sort  of  collar  which  embraced  them.  Some 
of  the  vesicles  were  very  vascular,  receiving  little  trunks  of 
vessels,  which  ran  along  the  fibrous  bands.  The  vesicles  could 
be  enucleated  entire.  They  appeared  to  be  formed  by  a  base 
ment  membrane,  epitheliated  internally,  and  covered  externally 
with  shreds  of  fibrous  tissue.' 

The  meshes  of  the  tumour  removed  in  Case  No.  104  varied 
very  much  in  size.  The  great  majority  of  them  appeared  to  be 
about  the  size  of  a  pin's  head,  and  separated  from  each  other 
by  partitions  about  one  quarter  of  a  line  thick  ;  some  of  them, 
however,  were  three-eighths  of  an  inch  broad,  and  one  inch  or 
more   long.     The   walls  of  these  were   considerably  (perhaps 


four  times)  thicker  than  the  others  ;  they  could  be  dissected 
free,  and  were  found  to  be  continuous  with  and  to  branch  from 
the  tunica  albuginea.  One  thing  is  worthy  of  notice — the 
larger  cysts  were  not  spherical,  but  elliptical. 

The  tumour  in  Case  No.  113  weighed  from  fifteen  to  twenty 
pounds  ;  its  texture  was  soft  and  friable,  so  that  in  handling 
it  tore  by  its  own  weight.  On  what  had  originally  been  its 
inferior  and  posterior  aspects  it  was  much  broken  up,  but  it 
was  impossible  to  say  how  much  of  this  was  due  to  the  operation 
itself,   how   much    had  been  antecedent  to  it.     The  external 


FIBROUS    TUMOUR  47 

surface  of  the  tumour  was  in  some  parts  marked  by  traces  of 
adhesions.  The  structure  of  the  tumour  was  tolerably  simple, 
and  is  well  shown  by  the  accompanying  engraving,  which  is  a 
section  perpendicular  to  the  surface,  and  reduced  to  a  quarter 
of  the  actual  size. 

The  investing  membrane,  the  tunica  albuginea  (a),  is  seen 
partially  in  profile ;  continuous  with  it  the  fibrous  trabecule 
(6)  enclose  small  spaces  (c) ;  these  spaces  were  filled  originally 
with  mucoid  fluid. 

FIBROUS   TUMOUR. 

A  true  fibrous  tumour  of  the  ovary  is  a  thing  of  very  rare 
occurrence,  so  rare  indeed  that  until  the  year  1872  not  one, 
distinctly  characterized  and  taking  its  origin  in  the  ovarian 
tissues,  ever  came  under  my  observation.  And  it  will  be  found 
that  many  cases  reported  as  ovarian  fibroids  are  in  reality 
tumours  beginning  in  the  uterus,  which  overgrow  and  in- 
volve the  ovary  so  as  to  disguise  its  natural  appearance  or 
conceal  it  altogether.  Kiwisch  maintains  that  he  has  found 
round  solid  fibroids  of  considerable  extent  in  two  cases ;  in 
the  one  the  size  of  a  child's  head,  in  the  other  about  as  large 
as  a  small  adult  head.  Such  tumours  have,  he  says,  in  general, 
very  little  tendency  to  undergo  dangerous  metamorphosis, 
though  in  the  Surgical  Clinique  at  Prague  he  lost  a  patient  by 
what  he  calls  '  partial  decomposition  of  an  ovarian  fibroid.' 

Speaking  from  personal  observation,  there  seems  reason  to 
doubt  the  correctness  of  the  diagnosis  in  these  reports.  Indeed, 
more  than  a  hundred  cases  are  on  record  where  the  abdomen  has 
been  opened  with  the  object  of  removing  an  ovarian  tumour, 
but  the  operator  discovered,  after  making  the  incision,  that 
the  tumour  was  not  ovarian,  but  uterine.  And  further,  some 
of  the  tumours  actually  removed,  and  believed  by  the  operator 
to  be  ovarian,  have  been  proved  on  careful  examination  to  be 
really  fibroid  outgrowths  from  the  uterus,  more  or  less  pedun- 
culate. In  one  case  of  excision  of  a  pedunculate  fibro-cellular 
outgrowth  from  the  fundus  uteri,  I  only  discovered  what  I  had 
done  by  finding  both  ovaries  healthy,  and  when  this  tumour 
was  exhibited  at  one  of  our  Societies  I  had  difficulty  in  con- 
vincing some  of  the  Fellows  that  it  was  not  ovarian. 


48  RARITY    OF    FIBROMA    OF    OVARY 

In  the  year  1871a  specimen  shown  at  the  Obstetrical  Society 
of  London,  illustrating  an  operation  for  double  ovariotomy,  was 
reported  on  by  Dr.  Meadows  and  Mr.  Scott  as  being  composed 
of  hard,  dense  fibrous  tissue,  but  having  in  some  places  a  kind  of 
reticulated  appearance.  Under  the  microscope  it  was  seen  to 
consist  of  white  fibrous  tissue,  some  elongated  fibre  cells,  and 
a  few  rounded  granular  cells  and  granules.  The  reporters 
added  that  it  seems  possible  that  the  tumour  originated  in  the 
fibrous  stroma  of  the  ovary,  and  that  its  growth  in  one  direc- 
tion did  not  interfere  with  that  portion  of  the  ovary  which  still 
maintained  its  normal  character,  and,  so  far  as  could  be  judged, 
performed  its  ordinary  function.  Dr.  Wilson  Fox  also  re- 
ported on  the  same  tumour,  and  states  it  to  be  a  '  loculated 
fibroid ;  but  in  the  more  central  and  transparent  parts  of  the 
loculi  there  are  a  great  number  of  non-striated  muscular  fibres. 
It  is  very  difficult  to  isolate  non-striated  muscle  after  a  prepa- 
ration has  been  in  spirit,  but  there  are  a  number  of  broad- 
banded  fibres  not  affected  by  acetic  acid  (as  the  surrounding 
bundles  of  fibrous  tissue  are)  and  containing  long  fusiform 
nuclei.'  The  remains  of  the  ovary  appeared  to  me  to  be  separ- 
able from  the  tumour  ;  and,  while  not  denying  the  possibility 
of  a  tumour  largely  made  up  of  non- striated  muscular  fibre  ori- 
ginating in  the  ovary,  I  think  it  must  be  excessively  rare,  as 
I  have  seen  but  few  examples ;  whereas  originating  from  the 
uterus  they  are  among  the  most  common  of  morbid  growths. 
In  the  spring  of  1872,  however,  I  twice  operated  for  what  were 
really  fibrous  tumours  of  the  ovary,  the  right  in  both  cases. 
One  weighed  nine  ounces,  the  other  four  pounds  and  a  half. 
There  was  a  large  quantity  of  fluid  in  both  the  peritoneal 
cavities.  One  patient  was  in  the  third  month  of  pregnancy, 
the  other  a  single  lady.  Both  recovered.  One  of  these 
tumours  is  now  in  the  Museum  of  the  College  of  Surgeons. 
The  first  of  these  was  a  solid  mass  weighing  five  pounds  six 
ounces.  The  second  was  much  larger,  and  amounted  to  twenty- 
three  pounds  six  ounces.  In  this  case  there  was  an  indistinct 
sense  of  fluctuation,  which  was  supposed  to  be  masked  by  fat. 
The  next  time  I  found  both  ovaries  in  the  same  condition  and 
took  them  away.  The  patient  recovered,  but  died  a  year  after. 
I  met  with  another  such  tumour  of  about  fifteen  pounds,  in 
1879,  and  in  this  lady  there  was  a  large   quantity  of  ascitic 


CANCER    OF    OVARY  49 

fluid,  present.     She,  however,  remains  quite  well  at  the  end  of 
1881.  . 


CANCER. 

The  ovaries,  like  all  other  parts  of  the  human  body,  be- 
come the  seat  of  cancerous  disease.  It  assumes  no  special 
forms  in  them.  Every  kind  of  cancer  infesting  other  organs 
is  in  turn  reproduced  in  the  ovary.  The  peculiarity  of  its 
tissues  and  the  arrangements  of  its  component  parts  per- 
haps in  some  respects  facilitate  the  development  of  the  disease. 
The  fibrous  stroma,  the  dense  investment,  the  abundant  groups 
of  innocent  reproductive  vesicles,  and  the  ever-growing  intra- 
follicular  epithelium,  seem  respectively  typically  to  prefigure 
the  forms  of  scirrhous,  colloid,  papillary,  and  medullary  cancer. 

Paget  says  (p.  613,  edition  by  Turner):  'The  most  re- 
markable examples  of  hard  cancers  with  fibrous  structures  that 
I  have  yet  seen  have  been  in  the  ovaries  of  certain  patients 
with  common  hard  cancer  of  the  breast  or  stomach.  In  these 
cases  the  place  of  the  ovary  on  either  or  on  both  sides  is  occu- 
pied by  a  nodulated  mass  of  uniformly  hard,  heavy,  white,  and 
fibrous  tissue.  The  mass  appears  to  be,  generally,  of  oval  form, 
and  may  be  three  or  more  inches  in  diameter.  Its  toughness 
exceeds  that  of  even  the  firmest  fibrous  tumours,  and  its  com- 
ponent fibres,  though  too  slender  to  be  measured,  are  peculiarly 
hard,  compact,  closely  and  irregularly  woven.  They  are  not 
undulating,  but  when  they  can  be  separated,  singly  or  in 
bundles,  they  appear  dark-edged,  short,  and  irregularly  netted. 
With  these  I  have  found  only  few  and  imperfect  cancer-cells, 
with  more  numerous  nuclei,  elongated  and  slender.  They 
are  not  mingled  with  elastic  or  other  "yellow  element" 
fibres.' 

The  tendency  of  the  cystic  form  of  tumours  to  degenerate 
into  that  known  as  colloid  cancer  is  very  apparent.  But  the 
colloid  characteristics  may  be  present  from  the  very  commence- 
ment of  the  disease  and  occupy  the  whole  organ ;  while  in  some 
cases  all  the  conditions  coexist,  and  in  the  same  tumour  are 
found  cysts  with  an  almost  pure  fluid,  other  spacea  with  the 
jelly-like  contents,  and  some  again  exclusively  filled  with  the 
dendritic  epithelial  growths  passing  into  the  soft  state  of  medul- 

E 


50  CANCER   OF   OVARY 

lary  cancer.  The  colloid  cancer  is  a  sort  of  intermediate  form 
of  disease,  having  intimate  alliances  and  resemblances,  on  the 
one  hand,  with  the  innocent  single  cysts,  and,  on  the  other,  often 
being  intermingled  and  confused  with  the  most  rapidly  spread- 
ing and  malignant  cancer  growths.  It  grows  quickly  and  largely, 
but,  not  having  a  tendency  to  destroy  life  by  reason  of  any 
special  poisonous  virulence  contaminating  the  whole  system,  it 
is  seldom  that  there  is  an  opportunity  of  examining  the  prim- 
ary stages  of  its  formation,  except  when  tumours  have  been 
removed  by  operation.  They  consist  of  a  mass  of  countless 
alveoli,  often  involving  the  entire  ovarian  structure,  and  acquir- 
ing a  bulk  equal  to  that  of  any  of  the  cystic  tumours,  and  fill- 
ing up  the  pelvis  and  abdomen.  These  cells,  or  alveolar  spaces, 
are  of  all  sizes  ranging  upwards  from  that  invisible  to  the  naked 
eye.  In  some  parts  the  appearance  is  that  of  fine  sponge,  and 
in  others  the  alveoli  expand  into  the  round  or  oval  form  of 
cysts.  Generally  some  of  these  larger  cysts  grow  and  pre- 
dominate over  the  others,  and  form  protuberances,  or  projec- 
tions on  the  surface  of  the  mass.  Many  of  the  spaces  com- 
municate with  each  other,  though  there  are  generally  indica- 
tions that  they  were  all  originally  separate.  The  partitions  of 
the  alveoli  are  made  up  of  white,  shining,  and  firm  though 
delicate  fibrous  tissue ;  and,  in  the  case  of  dividing  large  spaces, 
have  considerable  thickness  and  are  not  sparingly  vascular. 
The  smaller  cavities  are  often  only  limited  by  membrane  of 
extreme  tenuity,  and  it  does  also  happen  that  occasionally  even 
the  larger  accumulations  of  semi-fluid  matter  are  only  held 
together  by  the  finest  films  of  tissue.  The  contents  are  a 
tenacious,  viscid  matter.  Its  consistency  varies  from  set-jelly 
solidity  to  a  ropy,  glairy  mucoid,  which  may  be  drawn  out  into 
strings.  It  is  seldom  clear  and  colourless ;  often  brown  or 
yellowish,  or  even  a  pale  green,  having  mixed  with  it  flocculent, 
whitish,  creamy  substance,  and  many  epithelial  cells,  oil  drops, 
and  granular  matter. 

The  tumour  removed,  Case  No.  3,  Nov.  5,  1858,  from  a 
married  woman,  aged  thirty-three,  was  thus  described  at  the 
time  in  the  simplest  language,  without  any  theoretical  bias  as  to 
its  pathological  classification.  Some  two  or  three  pints  of 
its  contents  having  been  previously  emptied,  it  weighed  on 
removal  twenty-one  pounds.     The  external  capsule  was  firm, 


COLLOID    CYST    OF    THE    OVARY  51 

fibrous,  and  very  vascular  ;  section  showed  an  immense  number 
of  imperfect  cysts,  or  alveolar  cavities,  from  trie  size  of  a  pea 
to  that  of  a  small  apple ;  and  one  large  cyst,  which  had  con- 
tained from  two  to  three  pints  of  viscid  fluid.  The  walls  of 
the  cyst  and  alveoli  were  very  vascular,  inclosing  a  semi-opaque, 
jelly-like  substance,  varying  in  colour  from  white  to  dark  choco- 
late in  different  places,  and  in  consistence  from  that  of  firm 
jelly  to  that  of  white  of  egg.  By  a  little  pressure  this  matter 
was  made  to  exude  easily  from  the  divided  cavities.  Thus  the 
tumour  might  be  described  as  a  fibrous  network,  forming  irre- 
gular cavities  containing  gelatinous  matter.  After  maceration 
and  squeezing  out  the  contents,  the  septa  were  seen  to  form 
very  imperfect  separations  between  the  cavities.  A  great 
quantity  of  molecular  matter  was  seen,  with  free  nuclei,  and 
small  oval  cells  about  the  diameter  of  blood  corpuscles ;  also 
numerous  large  granular  corpuscles,  from  two  to  three  times 
the  diameter  of  blood  corpuscles,  and  an  abundance  of  oil 
globules.  When  exhibiting  this  specimen  at  the  Pathological 
Society  in  1859,  I  said:  'It  is  a  question,  however,  whether  the 
distinction  between  the  compound  ovarian  cyst  and  true  colloid 
disease  is  as  well  made  out  by  any  observation  of  minute 
structural  difference  as  in  the  clinical  history ;  especially  in  the 
important  fact  that  the  former  disease  shows  no  tendency  either 
to  reproduction  in  distant  parts  of  the  system,  or  to  contami- 
nate neighbouring  parts  or  glands.' 

The  subsequent  history  gives  some  importance  to  these 
remarks.  The  woman  made  a  rapid  and  uninterrupted  recovery, 
and  remained  well  for  some  months,  doing  field  work,  and 
having  gained,  early  in  1859,  fifteen  pounds  in  weight.  But 
in  July  she  began  to  suffer  from  symptoms  of  chronic  peri- 
tonitis, followed  by  those  of  obstructed  intestines,  and  died  on 
August  26. 

Mr.  Jardine,  of  Capel,  near  Dorking,  sent  me  one  specimen 
taken  from  the  body,  which  showed  a  portion  of  the  abdominal 
wall,  containing  the  cicatrix,  the  peduncle  of  the  removed 
ovary  adhering  to  it,  and  connecting  it  closely  with  the  uterus ; 
and  the  left  ovary,  in  which  disease  had  commenced,  and  gone 
on  to  the  formation  of  a  compound  cyst  about  the  size  of  a 
-mall  orange.  Another  specimen,  which  I  also  preserved  and 
laid  before  the  Pathological  Society,  showed  two  strictures  of 

E  2 


62  EPITHELIAL    CHANGES    IN    CYSTS 

the  ileum,  very  near  the  caecum,  caused  by  cancerous  deposit 
between  the  peritoneum  and  muscular  coat  of  the  intestine. 
A  similar  deposit,  in  small  nodules,  had  been  strewed  over 
nearly  the  whole  of  the  peritoneum  and  its  reflections.  Mr. 
Jardine  examined  the  structure  of  these  nodules  microscopically, 
and  reported  as  follows :  '  The  masses  are,  when  small,  only 
between  the  peritoneum  and  muscular  coat  of  the  intestines, 
and  have  a  distinct  limiting  membrane  of  their  own ;  nowhere 
appearing  to  be  infiltrating  growths.  As  they  increase,  the 
general  tendency  seems  to  be  to  push  out  the  peritoneum,  and 
to  become  pedunculated,  rather  than  to  spread  flatly  under  it. 
The  bulk  is  composed  of  cells  about  the  size  of  pus  corpuscles, 
with  large  nuclei  (in  some  cases  almost  filling  up  the  cells), 
refracting  light  more  strongly  than  the  cells  themselves.  Most 
of  the  cells  approach  the  globular  form,  but  many  are  fusiform 
and  elongated.  No  nucleoli,  but  some  oil  globules  in  cells, 
and  nuclei,  and  much  free  oil ;  a  small  amount  of  fibrous  tissue 
running  throughout,  but  not  with  definite  arrangement.' 

Simple  cysts  may  arise  in  the  ovary  and  do  nothing  more 
than  enlarge,  or  their  epithelium  may  degenerate  independently 
and  go  on  to  the  formation  of  the  worst  forms  of  epithelial 
cancer.  Dendritic  growths  spring  up ;  and  the  steps  of  their 
formation,  so  far  as  they  can  be  seen,  are  as  follows.  An 
epithelial  cell  elongates  and  projects  into  the  cyst  cavity — that 
is  to  say,  a  scale  of  tesselated  epithelium  becomes  columuar. 
The  columnar  epithelium  becomes  stratified  by  the  continued 
upward  growth  of  cells.  Lateral  offshoots  are  sent  out,  and 
these  offshoots  again  subdivide  into  minute  ramifications.  Shut 
cavities  may  be  formed  by  the  accidental  cohesion  of  their 
branches.  Loops  of  vessels  accompanied  with  fibrous  tissue 
grow  upwards  from  the  stroma  into  the  dendritic  formation. 
They  increase  rapidly,  and  soon  show  their  affinity  to,  and 
tendency  to  degenerate  into  the  condition  of  medullary  cancer. 
The  engraving  on  next  page  is  a  magnified  representation  of  the 
transverse  section  of  the  wall  of  an  ovarian  cyst,  which  is 
entirely  composed  of  fibrous  tissue,  except  at  its  upper  margin, 
where  it  is  epitheliated,  and  where  the  dendritic  growths  are  in 
active  progress. 

Simple  cysts  may  also  be  surrounded  with  colloid  or  medul- 
lary   o-rowths,  and    from  contact    or    close  proximity   may  be 


CANCER    OF    OVARY 


53 


induced  to  make  this  secondary  addition  to  the  general  mass  of 
disease.  Or  the  cystic  disease  of  the  ovary  may  advance  in  one 
part  after  the  simplest  manner,  while  in  some  other  part 
medullary  cancer  may  make  its  invasion  of  the  organ  in  its 
usual  way,  either  as  an  infiltration  of  the  tissues,  or  by  taking 
at  first  limited  action  and  giving  origin  to  a  capsulated  tumour, 
which,  after  enlarging,  softens,  yields  at  one  point  of  its  coats, 
and  shoots  forth  fungous  outgrowths. 

But  sometimes  the  true  cancerous  disease  attacks  the  ovary 
without  any  preliminary  formation  of  cysts,  destroys  its  struc- 
ture, speedily  runs  over  the  peritoneum,  and  insinuates  itself 
into   the    lymphatics,   glands,    and    viscera.      The    disease   is 


usually  one  of  middle  or  advanced  life,  but,  in  one  of  the  cases 
reported  hereafter,  it  will  be  seen  that  the  age  of  the  patient  did 
not  exceed  fourteen  years.  Its  progress  is  rapid,  and  occasions 
the  pouring  out  of  ascitic  fluid,  and  many  other  complications 
perplexing  the  diagnosis.  In  all  the  three  patients  whose 
history  is  now  given,  the  question  of  ovariotomy  had  been  con- 
sidered, but  had  been  negatived,  both  by  local  conditions  of  the 
tumours,  and  by  the  visible  cachexia  indicative  of  malignant 
disease. 

Cancer  of  both  ovaries. — E.  A.  N.,  set.  44,  was  admitted  into 
the  Samaritan  rfbspital  on  June  3,  1&62.     Married  for  fourteen 


54  CANCEROUS    DISEASE 

years,  but  has  never  conceived.  No  hereditary  influence  can 
be  traced.  Three  years  ago  the  patient  discovered  a  tumour 
in  the  left  iliac  region  ;  at  first  it  was  not  painful,  but  pro- 
duced incontinence  of  urine.  After  some  months  this  latter 
symptom  disappeared,  and  about  a  year  ago  the  swelling  be- 
came so  painful  that  the  patient  was  obliged  to  confine  herself 
to  bed.  Six  months  later,  the  catamenia,  which  had  formerly 
been  regular,  ceased,  and  did  not  return.  Four  months  ago 
the  patient  was  tapped  in  St.  Bartholomew's  Hospital.  One 
hundred  and  fifty-eight  ounces  of  fluid  were  removed ;  but, 
after  the  operation,  a  large  solid  mass  remained  behind. 

On  admission  the  breathing  was  hurried  and  incomplete, 
the  legs  slightly  cedematous ;  the  girth  at  the  umbilical  level 
was  forty-one  inches,  the  distance  from  the  ensiform  cartilage 
to  the  symphysis  seventeen  inches.  The  whole  anterior  part 
of  the  abdomen  was  dull  on  percussion.  Fluctuation  very 
evident,  and  on  making  deep  pressure  the  fingers  impinged  on 
a  hard  body,  whose  outline  could  not  be  defined.  The  patient 
was  tapped  by  puncture  made  with  a  lancet,  and  fifteen  pints 
of  glairy  fluid  drawn  off  by  means  of  a  syphon.  After  riddance 
of  the  fluid,  the  tumour  was  found  to  stretch  from  the  left 
groin  across  the  abdomen  to  the  right  hypochondrium.  It  did 
not  appear  to  be  adherent  to  the  integuments.  Per  vaginam, 
several  hardish  immovable  masses  were  felt  behind  the  uterus. 
The  patient  became  gradually  weaker,  and  died  on  July  19. 

Ascitic  fluid  filled  the  peritoneal  cavity.  Both  ovaries  were 
diseased  and  increased  in  size,  and  contained  several  cysts. 
Dr.  Aitken,  of  Netley,  examined  portions  of  the  ovaries,  and 
reported  a  number  of  cysts,  some  simple,  some  proliferous,  and 
a  mass  of  malignant  growth  which  had  grown  to  and  encroached 
upon  the  rectum. 

Cancer  of  left  ovary  and  ascites.— E.  T.,  set.  59,  was  ad- 
mitted into  the  Samaritan  Hospital  on  December  6,  1863. 
Twice  married,  no  children,  no  hereditary  disease,  never  seri- 
ously ill  (with  the  exception  of  an  attack  of  pelvic  cellulitis, 
fifteen  years  ago),  but  living  in  a  crowded  part  of  London  and 
badly  nourished.     She  had  not  menstruated  for  five  years. 

Twelve  months  before,  a  tumour  was  found  in  the  hypo- 
gastrium.  Abdominal  enlargement,  ascites,  and  prolapse  of 
the  womb  quickly  followed.     She  was  then  relieved  by  tapping, 


OF   OVARIES  55 

which,  in  eight  months,  was  repeated  five  times  ;  the  evacuated 
fluid  was  described  as  being  thick  and  glairy. 

On  admission,  emaciation  considerable,  expression  anxious  ; 
the  skin  cool,  and  the  feet,  especially  the  left  one,  are  cold. 
The  patient  states  that  she  frequently  perspires  on  the  left  side 
of  the  body,  never  on  the  right.  The  left  leg  is  extremely 
cedematous,  and  its  veins  are  varicose.  She  always  sleeps  on 
her  back,  being  unable  to  turn  on  her  side  on  account  of  a 
rolling  weight  in  the  abdomen.  Pulse  104,  thready ;  sounds 
of  heart  normal ;  urine  slightly  diminished  in  quantity,  with  a 
copious  deposit  of  urates.  Considerable  pain  before  and  after 
micturition.  On  examination,  the  abdomen  measures  at  the 
umbilical  level  thirty-nine  inches  in  circumference,  while  the 
distance  from  the  ensiform  cartilage  to  the  pubic  symphysis  is 
fifteen  and  a  half  inches.  The  superficial  veins  of  the  abdomen 
are  dilated;  the  lower  ribs  pushed  outwards,  and  the  liver 
somewhat  displaced  in  an  upward  direction.  Fluctuation  is 
very  distinct,  being  evidently  due  to  a  collection  of  ascitic 
fluid.  Crepitus  is  both  to  be  felt  and  heard  on  the  right  side. 
On  making  deep  pressure,  a  resistant  nodulated  tumour  is  felt, 
filling  the  hypogastric  and  part  of  the  iliac  region ;  its  mobility 
is  very  limited,  its  tenderness  not  very  great.  Vagina 
cedematous ;  os  uteri  virginal ;  uterus  retroverted. 

In  December,  sixteen  pints  of  a  yellowish  fluid,  not  unlike 
pale  ale,  of  a  specific  gravity  of  1020,  were  taken  away  by 
tapping.  It  was  highly  albuminous,  and  under  the  microscope 
it  was  found  to  contain  red  and  white  blood  corpuscles.  After 
tapping,  the  patient  became  very  faint ;  but  she  rallied  and 
lingered  on  till  February  26,  1864,  when  she  died  exhausted. 

The  post-mortem  revealed  the  presence  of  some  ascitic  fluid, 
of  cancerous  warts  on  the  peritoneum,  and  of  a  large  multi- 
locular  tumour  of  the  left  ovary.  This  tumour  was  adherent 
in  front  to  the  bladder,  behind  to  the  rectum,  and  on  the  left 
to  the  pelvis  itself,  as  high  as  the  crest  of  the  ilium.  The 
adhesions  were  too  strong  to  be  torn,  and  the  tumour  was 
almost  immovably  fixed.  The  right  ovary  was  also  the  seat  of 
cystic  degeneration.  The  tumour  of  the  left  ovary  was  carefully 
examined,  and  exhibited,  in  different  parts,  unmistakable  appear- 
ances of  cancer. 

Soft  cancer  involving  the  ovaries  of  a  child. — January  19, 


5$  OVARIAN    CANCER 

1864,  saw  the  patient  with  Mr.  Berry.  E.  C,  a  scrofulous 
child,  aet.  thirteen  years  nine  months,  began  to  menstruate 
eight  months  ago  ;  four  months  later  she  had  an  attack  of 
erysipelas  of  the  face  and  head,  from  which  she  recovered 
tolerably  well.  Five  or  six  weeks  ago  she  was  troubled  with 
constant  desire  to  make  water,  and  two  weeks  later  the  cata- 
menia  came  on  ;  since  then  they  have  never  ceased.  Simul- 
taneously with  the  appearance  of  the  catamenia,  a  small  tumour 
was  observed  in  the  hypogastrium.  At  first  it  increased  slowly, 
but  within  the  last  three  days  it  has  reached  its  present  dimen- 
sions. There  was  a  distinct  firm  tumour  filling  up  the  whole 
of  the  abdomen  below  the  umbilical  level.  It  was  not  tender 
on  pressure,  and  fluctuation  was  very  indistinct;  impulse, 
however,  being  well  marked.  The  tumour  was  firmly  fixed. 
The  superficial  abdominal  veins  were  considerably  dilated,  and 
inosculated  freely  with  those  of  the  mammas.  Per  vaginam, 
the  uterus  was  found  to  have  been  pressed  high  up,  by  a  tumour 
behind  it  and  in  front  of  the  rectum. 

Mr.  Berry  tapped  the  patient  at  a  point  midway  between 
the  umbilicus  and  anterior  superior  spinous  process  of  the  ilium. 
Three  or  four  ounces  of  straw-coloured  fluid  came  away,  and 
were  followed  by  a  discharge  of  pure  blood.  Only  two  and 
a  half  ounces  of  blood  were  lost,  but  the  little  patient  became 
very  weak  and  faint.  The  fluid  consisted  of  ordinary  serum 
with  granular  corpuscles. 

The  tumour  increased  rapidly,  and  could  be  felt  midway 
between  the  umbilicus  and  ensiform  cartilage;  more  fluid 
accumulated,  and  was  removed  by  tapping  per  vaginam. 

The  patient  died  on  March  5.  At  the  post-mortem  three 
to  four  pints  of  fluid  escaped  on  opening  the  abdomen.  The 
tumour  was  firmly  fixed  in  the  pelvis,  and  was  glued  to  the 
intestines.  It  was  removed  along  with  the  uterus  and  bladder, 
and  sent  to  Dr.  Wilson  Fox,  who  found  encephaloid  cancer  of 
the  bladder  and  of  posterior  wall  of  the  uterus.  *  The  tumour 
consists  of  a  cystic  portion,  whose  periphery  is  covered  with 
cancerous  nodules,  and  of  a  solid  portion,  from  which,  by 
scraping,  a  milky  juice  exudes.  Microscopically,  the  closest 
resemblance  is  found  between  the  ovarian  disease  and  that  of 
the  other  cancerous  nodules.  The  general  structure  in  both 
was  that  of  cells  and  nuclei  imbedded  in  a  stroma  of  fibres  with 


IN    A    CHILD  57 

large  nuclei  and  capillary  vessels.  The  greater  portion  of  the 
juice  scraped  from  the  tumour  presented  nothing  but  free 
molecules  and  nuclei.  They  are  round,  or  irregularly  oval,  and 
have  an  average  diameter  of  1  iQ0  to  -joVo"  m*  They  have 
granular  contents,  and  a  clear  nucleolus.  In  addition  to  these 
a  few  larger  ovoid  ones  were  seen  ;  also  elongated  spindle-shaped 
cells,  with  elongated  nucleus  and  clear  nucleolus,  which  pro- 
bably belong  to  the  stroma  or  to  growing  vessels.  Very  few 
larger  cells  were  seen,  and  these  were  chiefly  observed  in  the 
ovary.  It  contained  numerous  nuclei,  having  an  average 
diameter  of  -g^or,  eacn  w^h  a  bright,  clear  nucleolus.  The 
diameter  of  the  cell  was  g-J-g-  in. ;  its  walls  were  well  denned, 
and  its  contents  darkly  nebulous.  Cells  were  also  seen  occa- 
sionally, having  a  diameter  varying  from  ygVo  ^°  tbVo  ^n' » 
in  some  cases  with  a  large,  single  nucleus,  in  others  with  a 
double  nucleus.  In  one  part  of  the  field  a  body  was  seen  which 
strongly  resembled  an  immature  Graafian  follicle  undergoing 
degeneration.  It  had  an  appearance  of  fibrillation  around  the 
whole  of  its  circumference,  certainly  more  than  could  be 
attributed  to  any  thickening  or  folding  of  the  cell-wall.  The 
whole  contents  were  rather  darkly  granular,  but  around  the 
inner  margin  were  indistinct  traces  of  cell-structure,  such  as 
is  seen  in  the  membrana  granulosa  of  mammalian  Graafian 
follicles.  It  was  circular,  or  nearly  so,  and  had  a  diameter  of 
5^-p  in.  In  the  thicker- walled  cyst  was  contained  some  milky 
fluid  ;  in  section,  the  whole  of  the  wall  was  found  occupied  with 
a  cancerous  growth. 

*  On  section  of  part  of  the  walls  of  one  of  the  thinner- walled 
cysts,  a  clear,  semi-transparent,  not  viscid  fluid  exuded.  The 
walls  correspond  in  structure  with  that  of  the  thinner-walled 
ovarian  cysts  seen  in  multilocular  tumours  of  the  ovary.  The 
wall  was  fibrous,  with  many  spindle-shaped  cells  interlacing 
in  a  series  of  meshes  and  mingled  with  finer  areolar  tissue. 
Cancer-cells  were  only  seen  in  a  few  places  in  the  wall.  The 
epithelial  lining  had  disappeared  in  a  great  measure  from  the 
interior.  (Post-mortem  change?)  Here  and  there  were  a  few 
flattened  cells.  At  the  inner  boundary  a  few  swollen  and 
granular  cells  are  still  adhering  ;  these  latter  are  indistinctly 
nucleated.  At  one  spot  a  villous,  cancerous  growth  was  seen 
projecting  into  the  interior  of  the  cyst.     These  cysts  must  be 


58  TUBERCLE 

regarded  as  Graafian  follicles  in  which  the  ovum  has  perished, 
and  the  membrana  granulosa  also  been  destroyed.  As  a  con- 
sequence, they  had  become  somewhat  distended  by  a  serous 
secretion,  and  were,  at  the  time  of  observation,  in  the  course 
of  invasion  by  the  cancerous  growth.  The  relation  of  the  cancer 
of  the  ovary  to  that  of  the  other  tissues  must,  I  think,  be 
regarded  as  somewhat  doubtful.' 

Of  twenty  patients,  in  whom  I  made  exploratory  incisions 
followed  by  drainage,  eleven  died  within  fourteen  days  of  the 
operation,  and  nine  of  these  had  some  form  of  malignant  dis- 
ease. Five  of  the  nine  recoveries  were  well  a  few  years  later,  one 
died  at  the  end  of  nine  months,  and,  it  may  be  presumed,  from 
continuance  of  cancer  ;  of  three  there  is  no  further  history. 

TUBERCLE. 

Rokitansky  denied  altogether  the  fact  of  tubercle  being 
found  in  the  ovary.  Other  pathologists  speak  of  it  as  rare, 
and  as  generally  associated  with  similar  disease  of  the  peri- 
toneum and  other  organs.  A  large  cyst  was  removed  from 
a  single  lady,  set.  23,  who  died  five  days  after  the  opera- 
tion from  diffuse  peritonitis  of  a  low  form,  probably  tuber- 
cular. Dr.  Wilson  Fox  carefully  examined  the  specimen, 
and  described  the  cyst  as  single,  with  the  exception  of  a  few 
scattered,  thin-walled  cysts  on  the  inner  surface.  On  the  outer 
surface,  beneath  the  peritoneal  coat,  and  firmly  blended  with 
the  surrounding  stroma  of  the  cyst- wall,  there  were  numerous 
nodules  about  the  size  of  peppercorns,  of  a  cartilaginous 
hardness,  appearing  on  section  glistening  and  semi-transparent 
at  the  circumference,  and  opaque  and  cheesy  at  the  centre, 
which  was  slightly  softened.  The  nodules  themselves  were 
without  any  trace  of  vessels,  but  the  tissue  around  each  nodule 
was  very  highly  injected,  and  in  the  injected  area  there  were 
delicate  false  membranes  studded  with  the  finest  granulations 
of  miliary  tubercle.  False  membranes  were  also  seen  on  other 
parts  of  the  tumour,  containing  fine  granulations  of  miliary 
tubercle ;  and  similar  gray  granulations,  not  larger  than  a 
pin-point  or  a  poppy-seed,  on  some  parts  of  the  outer  wall  of 
cyst.  Under  the  microscope,  the  outer  part  of  the  larger 
masses  and  small  gray  granulations  were  observed  to  have  the 


*    STRUCTURE  OF  THE  PEDICLE  59 

same  structure,  and  to  consist  of  slightly  elongated  cells,  con- 
taining large,  round,  very  clear,  highly  refracting  nuclei,  each 
nucleus  containing  a  nucleolus.  The  nuclei  were  in  some  parts 
free.  In  some  parts  of  the  field,  cells  with  two  nuclei  could 
be  found  ;  these  were  imbedded  in  a  clear,  separating,  finely 
striated,  and  very  firm  inter-cellular  substance.  The  cells 
averaged  -j^^  in.  in  diameter,  the  nuclei  -j^Vo*  ^e  c^eesy 
yellow  matter  in  the  centre  of  the  nodules  consisted  of  oil 
globules,  granular  debris,  and  shrivelled  cells.  From  these 
characters,  Dr.  Fox  had  no  doubt  that  the  nodules  and  gray 
granulations  were  of  tubercular  nature. 

I  have  since  met  with  several  other  cases  in  which  there 
was  tuberculous  deposit  in  ovarian  tumours. 

THE    PEDICLE. 

For  the  sake  of  convenience,  the  attachment  of  these 
ovarian  cysts  and  tumours  to  the  part  from  which  they  spring, 
whether  long,  narrow,  and  cord-like,  or  short,  thick,  and  broad, 
may  be  considered  under  the  common  designation  of  pedicle. 
It  consists  of  the  Fallopian  tube  often  much  elongated,  the 
broad  ligament  often  considerably  thickened,  the  utero-ovarian 
ligament  in  some  cases  hypertrophied  into  a  large  fibroid  stem, 
and  the  round  ligament.  The  round  ligament  may  be  so  con- 
voluted that  a  double  curve  of  it  is  included  in  the  pedicle, 
but  it  is  often  quite  free.  Occasionally  the  utero-ovarian 
ligament  and  the  Fallopian  tube  are  not  connected  by  the 
broad  ligament ;  a  considerable  space  may  intervene  between 
them,  so  that  they  appear  as  two  pedicles  to  one  tumour. 
The  pedicle  always  contains  large  blood-vessels ;  every  now  and 
then  the  veins  are  so  large  and  distended  that  they  resemble 
the  intestines  of  a  rabbit.  In  all  cases  of  ovarian  tumour  the 
arteries  are  branches  from  those  which  supply  the  ovary  itself, 
and  the  veins  continue  to  show  the  tortuous  distribution 
peculiar  to  the  plexuses  of  this  part.  The  size  of  these  vessels, 
when  adhesions  do  not  materially  contribute  to  the  supply  of 
nourishment,  is  mostly  in  proportion  to  the  bulk  of  the  tumour, 
but  oftentimes  their  volume  is  inexplicably  large,  and  accounts 
for  the  rapid  loss  of  blood  when  ruptured  or  divided.  Numerous 
lymphatics    after   a   devious   course   and    many   inosculations 


60  PECULIARITIES    OF   THE   PEDICLE 

passing  between  the  ovary,  the  tube,  and  the  broad  ligament 
to  the  lumbar  plexus  are  also  inclosed  in  the  pedicle,  and 
nerves  of  considerable  size  accompany  the  vessels.  I  have  seen 
a  nerve  quite  as  large  as  the  radial  in  a  part  of  the  pedicle  left 
above  the  clamp.  The  tissues  mixed  up  with  the  other 
components  of  the  pedicle  are  histologically  the  same  as  those 
of  the  coats  of  the  tumour — a  species  of  imperfect  connective 
and  fibrous  tissues,  the  chief  elements  being  single  white 
fibres,  numerous  fusiform  embryonic  fibres,  and  elliptical  round 
cells  or  granules,  the  whole  being  coherent  and  strongly  con- 
tractile. All  is  bound  together  by  an  envelope  of  peritoneum 
reflected  from  its  base  of  attachment  and  continuous  with  the  ex- 
pansion over  the  tumour.  In  many  cases,  especially  where  the 
disease  assumes  the  colloid  form,  the  pedicle  becomes  implicated^, 
is  soft  in  texture,  and  easily  broken  through.  In  others  it 
becomes  the  seat  of  numerous  proliferous  outgrowths  or  papillary 
excrescences.  But  in  its  ordinary  form  as  described,  it  is  to  a 
great  degree  extensible,  and  consequently  is  found  of  very  variable 
length  and  thickness.  When  elongated,  it  may  form  attachments 
to  the  surrounding  parts,  and  sometimes  is  the  cause  of  strangula- 
tion of  intestine.  It  is  not  often  that  it  is  seen  so  long  as 
in  Case  603,  where  it  measured  more  than  one  foot,  and  was 
accompanied  throughout  by  the  Fallopian  tube.  In  Case  844 
it  was  more  than  the  usual  length,  and  had  a  band  of  adhe- 
sion stretching  across  to  a  coil  of  intestine.  This  I  ligatured 
before  putting  on  a  clamp  to  the  pedicle.  There  are  also 
instances  of  duplicate  pedicles.  I  need  only  cite  two  or  three 
eases  among  my  last  five  hundred.  In  one  case  (502)  the 
pedicle  was  in  two  divisions  with  intestine  between  them. 
Two  distinct  pedicles  supported  the  cyst  in  Case  927,  but  the 
tube  only  was  tied.  The  patient  did  well,  and  is  alive  at  pre- 
sent. In  No.  841  I  met  with  the  singular  complication  of  four 
cysts  for  which  there  were  four  pedicles,  and  it  turned  out  that 
there  were  three  ovaries  present.  A  long  pedicle  allows  free 
scope  to  the  disposition  which  these  tumours  have  to  turn  upon 
themselves,  and  is  then  the  source  of  important  complications. 
In  1865  Eokitansky  published  a  paper  on  'The  Strangula- 
tion of  Ovarian  Tumours  by  Eotation.'  The  tumour  turns 
upon  its  axis,  and  the  pedicle  is  twisted  sometimes  as  much 
as  two  or  three  times  round.     The  occurrence  is  not  at  all  rare. 


ROTATION    OF    THE    PEDICLE  61 

Eokitansky  has  given  the  particulars  of  thirteen  cases,  eight 
of  which  he  found  in  making  autopsies  after  fifty-eight  deaths 
from  ovarian  disease.  The  same  thing  has  been  observed 
during  my  operations  at  least  some  eighteen  or  twenty  times, 
and  no  doubt  it  has  at  others  escaped  notice.  In  two  cases  it 
caused  death  before  operation. 

The  direction  of  this  rotation  is  not  at  all  constant ;  some- 
times being  inwards  towards  the  median  line,  sometimes  the 
reverse,  outwards.  The  tumour  may  also  rotate  obliquely, 
turning  over  backwards  or  forwards.  In  outward  rotation 
the  Fallopian  tube,  if  not  adherent  to  the  tumour,  becomes 
spiral  round  its  pedicle ;  if  adherent,  round  both  tumour 
and  pedicle.  In  inward  rotation,  the  first  half  turn  pushes 
the  tube  inwards  and  backwards.  Should  the  rotation  con- 
tinue, then  the  tube  forms  a  spiral  round  the  back  of  the 
tumour.  Or  it  may  be  altogether  exempt  from  participation 
in  the  turning.  The  uterus  is  pulled  in  the  direction  of  the 
rotation,  and  in  one  case  (106)  it  was  so  much  drawn  out  of  its 
place  that  I  was  led  to  suppose  I  should  find  close  adhesions, 
which  however  did  not  exist.  These  movements  seem  occa- 
sionally to  take  place  suddenly  and  quickly;  but  they  are 
gradual  in  other  cases ;  may  be  reversed,  and  recur.  Where 
the  rotation  is  not  complete,  the  motion  may  become,  as  it 
were,  slowly  oscillating.  The  pedicle  sometimes  gives  indica- 
tions of  these  changes  having  taken  place  repeatedly  or  habi- 
tually ;  and  general  symptoms,  such  as  sudden  accession  or  in- 
crease of  pain,  change  of  other  sensations  from  altered  relative 
position  of  the  tumour  and  viscera,  and  perhaps  some  difference 
in  the  external  contour  of  the  belly,  may  enable  us  to  conjec- 
ture the  time  of  their  commencement. 

But  if  the  rotation  has  taken  place,  and  the  pedicle  has 
become  twisted,  and  no  unwinding  of  it  follows,  what  may  be 
the  consequences  ?  The  great  veins  are  compressed,  and  blood 
continues  to  pour  in  by  the  arteries.  Congestion,  exudation  of 
serum,  extravasation  of  blood  into  the  cysts,  and  rupture  follow 
in  rapid  succession,  and,  unless  timely  relief  is  afforded  by 
ovariotomy,  the  patient  soon  sinks.  If  the  rotations  are  so 
complete  and  enduring  as  to  strangulate  the  arteries  of  the 
pedicle,  gangrene  is  inevitable.  But  supposing  the  revolving 
of  the   tumour  to  be   accomplished  more  tardily,  nutrition  is 


fi2  CASES   OF   TWISTING    OF    PEDICLE 

only  impeded,  and  the  more  happy  result  of  shrivelling  of  the 
walls  of  the  tumour,  with  absolution  of  the  contents,  occurs. 
The  remains  of  such  tumours  have  been  found  sometimes  in 
Douglas's  space  as  a  hard,  solid,  partly  cartilaginous  substance. 
Inflammatory  adhesions  binding  down  the  pedicle  have  also, 
without  twisting,  brought  about  the  atrophy  of  an  ovarian 
tumour.  In  other  instances,  the  constriction  of  the  vessels  by 
the  ehange  of  position  is  so  moderate  that  the  tumour  itself  is 
not  much  affected,  but  it  remains  stationary,  and  contracts 
adhesions  to  some  of  the  viscera,  and  cannot  be  replaced. 
Eokitansky  mentions  one  case  in  which  a  strong  cord-like  band 
so  ligatured  the  sigmoid  flexure  of  the  bowel  that  the  slightest 
change  of  position  rendered  it  impermeable.  The  bowel  has 
also  got  so  entangled  with  a  long  pedicle,  during  rotation,  as 
to  beeome  strangulated.  The  immediate  performance  of  the 
operation  of  ovariotomy  might  even  be  rendered  necessary, 
under  such  circumstances,  for  the  release  of  the  compressed 
and  obstructed  intestine.  Even  after  new  vascular  alliances 
have  been  formed  between  the  rotated  tumour  and  the 
omentum  or  viscera,  the  pedicle  has  by  some  means,  either 
tension  or  pressure,  been  divided.  In  such  a  state  of  trans- 
plantation, the  tumour  has  drawn  its  nutriment  through  the 
newly  formed  vessels  of  the  plastic  adhesions,  and  its  parasitic 
existence  has  not  been  much  less  vigorous  than  before.  Several 
examples  of  these  self-grafted  tumours  have  come  under  notice 
among  my  ovariotomies.  In  the  operation  in  Case  110,  per- 
formed in  November  1864,  the  incision  extended  from  two 
inches  above  the  umbilicus  to  five  inches  below  it.  There  was 
no  adhesion  to  the  abdominal  wall,  but  the  omentum  was 
strongly  attached  to  the  upper  part  of  the  cyst,  and  interlaced 
with  mesentery  from  below.  I  tapped  several  large  cysts  suc- 
cessively, got  the  tumour  out,  and  then  found  there  was  no 
pedicle.  It  appeared  that  the  tumour  derived  its  vascular 
supply  solely  from  the  omental  and  mesenteric  vessels.  The 
fundus  of  the  uterus  felt  rough,  but  there  was  no  tear  nor 
fracture  at  the  point  where  the  Fallopian  tube  must  have 
separated,  nor  was  there  any  bleeding ;  there  was  pretty  free 
haemorrhage  from  the  omental  vessels.  I  cut  away  some 
shreds  of  omentum,  and  tied  at  least  twelve  vessels  with  very 
fine  silk,  cutting  off  both    ends    of   the    ligatures   close,  and 


tfEATII    FROM    TWISTING    OF    PEDICLE  63 

returning  the  omentum  with  the  tied  vessels  into  the  abdomen. 
The  other  ovary  was  found  in  its  natural  position,  but  enlarged 
and  diseased.  It  too  was  removed,  and  the  patient  was  soon 
fully  re-established  in  health,  and  lived  till  the  year  1878. 
Another  instance  (Case  419)  was  that  of  a  married  woman  with 
five  children,  thirty-eight  years  of  age,  whose  mother  died  of 
dropsy  with  abdominal  tumour.  For  eighteen  years  and  through 
all  her  pregnancies  she  had  carried  a  dermoid  cyst.  When  two 
months  advanced  in  pregnancy  (May  1871)  I  operated  on  her 
without  hindrance  to  the  gestation.  The  tumour  being  dermoid, 
its  contents  would  not  pass  through  the  trocar,  but  gushed  out 
from  the  puncture.  The  cyst  was  then  drawn  out,  large  shreds 
of  very  vascular  omentum  and  a  coil  of  intestine  growing  to  it. 
On  separating  the  omentum  and  intestine,  it  was  found  that 
there  was  no  pedicle.  The  blood  supply  of  the  cyst  had  been 
kept  up  by  the  omental  vessels,  and  some  large  vessels  near  the 
csecal  appendix,  where  the  intestine  appeared  thick  and  con- 
tracted. Several  vessels  and  shreds  of  omentum  were  tied,  and 
returned  with  the  ligatures  cut  off  short.  At  the  full  term 
of  pregnancy  a  living  child  was  born  after  a  natural  labour  in 
December  1871.  She  was  well  in  1872,  but  this  year  suffers 
from  pulmonary  disease. 

It  is  very  easy  to  understand  that  an  ovarian  tumour  of 
almost  any  size,  provided  the  pedicle  be  not  short  or  broad,  and 
the  tumour  be  free  from  adhesion,  may  very  easily  rotate  and 
form  one,  two,  or  more  complete  twists  of  the  pedicle.  I  have 
several  times  unrolled  the  pedicle  before  applying  a  clamp  or 
ligature,  turning  round  the  tumour  three  or  four  times  before 
it  was  set  right — this  although  there  had  been  no  such  stoppage 
of  the  supply  or  return  of  blood  as  to  have  affected  in  any  remark- 
able degree  the  nutrition  or  appearance  of  the  tumour.  But  in 
other  cases,  the  veins  having  been  compressed  while  the  arterial 
supply  went  on,  successive  haemorrhages  have  taken  place.  I 
have  twice  known  sudden  death  so  caused.  I  once  went  with 
the  late  Mr.  Fowler,  of  Kennington,  to  operate  upon  a  lady  at 
Brixton,  when  we  found  that  she  had  died  unexpectedly  two 
hours  before  our  arrival.  The  post-mortem  examination  showed 
that  death  was  due  to  a  very  large  extravasation  of  blood,  first 
into  the  ovarian  cyst  and  then,  after  its  bursting,  into  the 
abdominal   cavity,  evidently   the    consequence    of  a   complete 


64  RECOVERY    AFTER    CYSTIC    HEMORRHAGE 

twist  of  the  pedicle  by  the  rotation  of  a  non-adherent  cyst.  In 
another  case  I  went  to  the  Hospital  for  Incurables  at  Putney  to 
see  a  patient  there  by  the  desire  of  Mr.  Cream.  She  had  been 
found  dead  that  morning  by  the  side  of  her  bed.  Though 
against  the  rules  of  the  Institution,  I  opened  her  abdomen  and 
removed  a  large  free  ovarian  cyst,  which  contained  more  than 
five  pounds  of  blood-clot,  the  bleeding  in  this  instance  also 
caused  by  a  long  twisted  pedicle.  These  are  the  only  two 
cases  of  sudden  death  I  have  seen,  but  I  have  many  times  known 
hsemorrhage  to  a  smaller  extent  lead  to  attacks  of  pain,  vomit- 
ing, and  imaginary  peritonitis  ;  and  more  than  once  such  extreme 
pallor  or  chloro-angemic  aspect  as  gave  rise  to  ungrounded  fear 
of  malignant  disease.  One  very  remarkable  case  of  this  kind 
was  a  lady  from  Moscow,  who  arrived  in  London,  May  1879, 
after  a  journey  which  was  interrupted  at  Berlin  by  an  attack  of 
severe  abdominal  pain  and  vomiting.  She  was  twenty-four 
years  of  age,  married  in  January  1873,  had  her  first  child  in 
November  of  that  year,  aborted  in  1875,  1876,  and  1877,  and 
gave  birth  to  a  second  child  in  October  1878.  In  1876,  before 
the  second  abortion,  she  observed  a  tumour  the  size  of  the  fist 
on  the  left  side  of  the  abdomen.  After  the  abortion  it  increased 
to  the  size  of  a  child's  head,  and  so  remained  during  the  subse- 
quent pregnancies.  The  last  labour  was  natural,  but  the  abdo- 
men continued  to  enlarge  until  she  left  Moscow  for  England  to 
consult  me.  She  was  detained  a  week  in  Berlin  by  the  symp- 
toms above  noticed,  attributable,  I  believe,  to  a  twist  of  the 
pedicle,  and  on  reaching  London  she  was  suffering  from  a 
recurrence  of  pain  and  vomiting.  She  was  extremelv  weak,  and 
so  very  white  and  bloodless  that,  fearing  no  time  was  to  be  lost, 
I  operated  after  she  had  been  three  days  in  London,  and  found, 
as  I  expected,  a  quantity  of  blood-clot  within  a  very  rotten 
cyst,  and  a  narrow  cord-like  pedicle  so  tightly  twisted  as  to  be 
almost  broken  off.  There  was  no  fetor.  Extensive  recent 
adhesions  to  omentum  and  coils  of  intestine  had  mainly  kept 
up  the  supply  of  blood  to  the  tumour  of  the  left  ovary.  The 
right  ovary  being  enlarged  and  cystic  was  also  removed.  The 
patient  recovered  without  any  fever,  soon  regained  her  colour, 
and  not  long  since  sent  me  a  coloured  photograph  portrait  to 
show  the  difference  between  her  striking  pallor  before  the 
operation  and  her  present  look  of  blooming  health. 


DEGENERATION    OF    CYST    WALLS  65 

The  generality  of  sessile  tumours,  extra-ovarian  and  extra- 
peritoneal, have  no  true  pedicle,  but  acquire  their  supply  of 
blood  by  numerous  vessels  entering  at  all  the  attached  parts. 
Some  of  the  extra-peritoneal,  however,  in  enlarging  from  their 
base,  drive  the  peritoneum  before  them.  This  then  makes 
a  band  or  cord  of  connection,  and  may  or  may  not  contain  a  few 
large  vessels,  but  does  not  assume  the  form  of  a  substantial 
stem  as  in  the  ovarian  cysts.  I  count  as  many  as  nineteen 
cases  of  enucleation,  or  no  pedicle,  among  my  last  five  hundred 
ovariotomies.  And  so  long  ago  as  1859,  when  relating  the 
history  of  my  third  case,  I  pointed  out  the  existence  of  pedun- 
culated extra-peritoneal  growths.  Mr.  Jardine's  description  of 
what  was  found  on  examination  is  printed  at  page  51. 

DEGENERATION    OF   CYST   WALLS. 

Ovarian  cysts,  and  more  especially  the  complicated  kinds, 
are  liable  to  become  inflamed,  either  spontaneously  or  as  the 
consequence  of  some  accident  or  operation,  such  as  tapping. 
The  disease  may  run  on  rapidly,  with  intense  symptoms  and 
general  peritonitis,  to  a  fatal  termination.  Or  it  may  be 
more  localised  and  lead  to  suppuration  in  some  cavities.  This 
may  go  on  for  some  time,  with  the  production  of  pus  as  in 
a  common  abscess,  or  the  contents  of  the  cysts  may  be  con- 
verted into  any  of  the  foul,  offensive  fluids,  the  result  of 
decomposition.  The  fatal  termination,  if  the  cyst  be  not  re- 
moved, may  be  due  to  diffuse  peritonitis,  but  more  com- 
monly to  septic  or  pysemic  fever,  the  result  of  blood  changes 
set  up  by  absorption,  or  by  admixture,  more  or  less  direct  through 
the  vessels  of  the  cyst,  of  the  putrid  fluids  or  gases  with  the 
blood.  In  other  cases  ulcerative  action  in  the  walls  takes 
place  :  they  thin,  give  way,  and  are  perforated.  The  point  of 
perforation  may  be  free,  and  allow  the  escape  of  the  contents 
into  the  abdominal  cavity,  followed  either  by  speedy  death  or  by 
chronic  peritonitis.  But  if  adhesions  have  glued  the  cyst  to 
the  abdominal  walls,  they  too  may  be  subject  to  the  same 
destructive  action,  and  a  fistulous  opening  will  be  formed 
through  them.  At  other  times  the  adhesions  have  been 
between  the  cysts  and  some  of  the  viscera.  The  uterus,  vagina, 
bladder,   and  rectum  are  sometimes   the  route  by   which    clis- 

F 


66  BURSTING    OF   CYSTS 

charge  takes  place ;  and  in  a  few  rare  cases  it  has  happened 
through  the  attached  Fallopian  tubes.  When  perforation  has 
taken  place  into  the  bladder  or  rectum,  sinuous  fistulous  chan- 
nels are  formed,  and  suppuration  may  continue  for  some  time, 
with  free  discharge  of  the  pus  by  the  natural  outlets.  But  the 
end  of  this,  if  not,  as  in  some  rare  case,  a  spontaneous  cure,  is 
either  death  by  pyaemia,  or  equally  fatal  exhaustion. 

In  some  instances  where  the  cyst  walls  have  contained 
bones,  their  sharp  points  and  angles  have  caused  the  giving  way 
of  the  tissues  ;  and  sometimes  the  other  accidental  formations 
of  a  dermoid  cyst  have  found  their  way  into  other  cavities,  gener- 
ally into  the  bladder.  Diffenbach  had  to  perform  cystotomy 
for  the  removal  of  a  piece  of  bone  which  thus  passed  from  an 
ovarian  cyst  into  the  bladder.  Perforation  may  also  take  place 
in  another  way,  as  a  consequence  of  the  slower  degenerative 
processes  going  on  in  the  walls  of  the  cysts.  The  contents 
accumulate  inordinately ;  the  vessels  are  pressed  upon  and 
constricted  or  obliterated  ;  the  blood  supply  is  diminished  ; 
thinning  of  the  wall  stroma  takes  place,  and  the  changes  of 
involution  set  in.  Spontaneous  rupture,  as  it  is  called,  occurs ; 
and  when  the  fluid  simply  rushes  into  the  abdomen,  death  is 
the  usual  consequence  of  the  induced  peritonitis.  Yet  cases 
of  cure  have  been  met  with  by  many  surgeons.  Oppolzer, 
Kiwisch,  Ulrich,  and  others  have  recorded  instances  of  such 
recovery. 

In  severalof  my  cases  of  ovariotomy  the  operation  was  per- 
formed after  the  cyst  had  burst  and  its  contents  had  escaped 
into  the  peritoneal  cavity.  The  peritoneum  has  been  found 
intensely  red,  thick,  soft,  or  villous,  and  occasionally  covered 
by  loosely  adherent  flakes  of  lymph.  Yet  the  result  has  been 
surprisingly  satisfactory.  The  irritating  cause  having  been 
removed,  the  irritation  has  subsided.  If  the  cause  had  not 
been  removed,  death  must  have  happened  at  no  distant  period, 
as  all  the  general  and  local  symptoms  of  chronic  diffuse  peri- 
tonitis had,  in  the  whole  series  of  cases,  followed  the  rupture. 
In  the  last  series  of  500  there  were  twelve  instances  of  burst 
cysts  before  operation  with  only  one  death,  2*4  per  cent.  At 
any  rate,  the  bursting  of  the  cyst,  or  the  filling  of  the  peri- 
toneum by  oozing  from  the  puncture  made  by  tapping  the  cyst, 
is  no  bar  to  the  operation  of  ovariotomy,  but  rather  a  reason 


PERITONEAL    IRRITATION    AFTER    PUNCTURE  67 

for  doing  it  without  delay.  The  fluids  found  in  the  peritoneal 
cavity  have  been  of  all  kinds — simple,  bloody,  and  fetid ;  the 
cyst  walls  in  all  stages  of  degeneration,  some  even  nearly  black 
with  ragged  edged  openings ;  and  the  peritoneum  always  with 
the  same  signs  of  inflammatory  action,  though,  perhaps,  in 
the  fatal  cases  the  semi-organised  lymph  patches  were  more 
general. 

To  illustrate  this  point  in  the  history  of  ovarian  pathology, 
it  may  be  well  to  cite  some  notes  of  Case  200,  which  is  a  type 
of  all  the  rest.  This  patient  was  a  lady,  thirty-seven  years  of 
age,  mother  of  six  children,  whom  I  saw  with  Sir  Thomas 
Watson  and  Dr.  A  Farre  in  1866.  I  had  previously  removed 
an  ovarian  tumour  from  a  daughter  of  her  mother's  sister,  and 
have  since  done  the  same  for  another  patient,  the  daughter  of 
another  sister  of  her  mother,  thus  making  up  a  series  of  three 
cousins,  children  of  three  sisters,  none  of  whom  have  ever 
shown  any  sign  of  the  disease — a  curious  fact  in  relation  to 
cystic  pathology.  An  ovarian  tumour  and  vaginal  cystocele 
were  recognized,  and  twenty-three  imperial  pints  of  fluid  were 
removed  by  tapping.  The  fluid  rapidly  formed  again,  and  I 
removed  the  cyst  two  months  after  the  tapping.  Twenty-six 
pints  of  ovarian  fluid  were  free  in  the  peritoneal  cavity,  and  a 
thin-walled  multilocular  cyst,  which  appeared  to  be  a  simple 
hypertrophy  of  the  normal  constituents  of  the  left  ovary,  and 
weighing  only  two  pounds,  was  taken  away.  When  all  the 
fluid  was  sponged  from  the  peritoneal  cavity,  Dr.  Farre  and  I 
were  both  struck  with  the  intense  vivid  redness  of  the  mem- 
brane. It  was  thick,  soft,  velvety,  not  obscured  by  any  exuda- 
tion of  lymph,  but  all  over  the  abdominal  wall,  the  intes- 
tines, and  uterus,  it  was  as  brilliantly  red  as  a  microscopical 
injection.  We  were  naturally  apprehensive  of  the  effect  of 
the  incision,  sponging,  and  action  of  air  upon  a  serous  mem- 
brane in  this  condition,  and  I  went  directly  after  the  operation 
to  tell  Sir  T.  Watson.  He  said,  'Are  you  sure  you  got  it 
all  out  ?  '  When  I  answered,  '  Yes,  quite  sure,'  he  replied, 
with  the  wisdom  of  a  great  clinical  teacher,  '  Then  let  us  hope 
as  the  irritating  cause  is  removed,  the  irritation  will  subside.' 
And  it  did  subside.  There  was  no  bad  symptom.  Recovery 
■was  complete.  She  had  her  seventh  child  born  thirteen  months 
afl it  i lie  operation,  and  has  had  another  since.     Of  the   many 

f  2 


68  ANAEMIC   TISSUES 

valuable  practical  lessons  for  which  I  am  indebted  to  Sir  Thomas 
Watson,  I  know  of  none  more  important  than  that  he  taught  in 
this  case.  It  has  been  a  guide  in  many  others  since  ;  and  when 
able  to  remove  an  '  irritating  cause,'  I  have  almost  always  found 
that  the  irritation  has  subsided. 

In  these  cases,  the  common  form  of  degeneration  is  that 
into  fat.  This,  indeed,  is  the  most  commonly  observed  stage  of 
retrograde  change  in  these  tumours,  the  primary  one  being  that 
of  an  anaemic  condition  of  the  fibrous  tissue.  There  are  very 
few  ovarian  cysts  in  which  it  is  not  seen  to  some  extent.  Here 
and  there  are  found  yellow  or  light  brown  patches  slightly 
raised  above  the  general  level,  with  a  fatty  or  lardaceous  deposit 
in  the  cells  of  the  areolar  tissue.  This  often  begins  in  the 
epithelial  lining,  and  spreads  to  the  adjacent  tissues,  involving 
and  pervading  sometimes  the  whole  thickness  both  of  walls  and 
septa.  In  this  way,  the  septa  yielding  to  pressure  of  the  con- 
tents, small  cavities  unite  to  make  large  cysts,  and  large  soft- 
ened cysts  burst  without  ulceration. 

The  wall  of  a  multilocular  ovarian  cyst  of  very  rapid  growth, 
taken  from  a  young  unmarried  Jewess  (Case  153),  displayed 
several  irregular  patches  of  a  dull  yellow  or  brownish  colour. 
On  examination  by  the  microscope,  the  patches  in  question 
were  found  to  consist  principally  of  white  fibrous  tissue,  but 
no  traces  of  fat  could  be  detected.  The  colour  was  probably 
due  to  non-vascularity,  the  patches  being  deprived  of  a  vascular 
supply,  owing  to  the  vessels  being  filled  with  clot,  and  being 
more  or  less  obliterated.  The  non-vascularity  of  the  patches 
was  due  to  congestion  of  the  vessels  in  the  immediate  neigh- 
bourhood, resulting  in  rupture  and  extravasation.  The  cyst 
wall  as  a  whole  was  beautifully  injected  with  blood,  the  portions 
surrounding  the  patches  only  showing  extravasation.  The 
extravasated  points  formed  two  circumvallated  lines,  as  shown 
in  the  accompanying  woodcut. 

The  vessels  leading  to  the  outer  circumvallation  were  large 
and  numerous ;  those  leading  to  the  inner  circumvallation 
being  smaller  and  fewer  in  number.  The  patches,  with  the 
circumvallated  lines,  may  be  said  to  form  three  distinct  areas : — 

1.  An  area  where  the  vessels  were  numerous  and  large,  and 
where  great  quantities  of  blood  of  a  bright  florid  colour  were 
effused. 


OF   CYST    WALLS 


69 


2.  An  area  where  the  vessels  were  smaller  and  partially 
emptied  of  their  contents,  and  where  the  effusion  was  less 
highly  coloured  and  less  distinctly  marked. 

3.  An  area  in  which  the  remnants  only  of  vessels  could  be 
traced,  and  where  no  effusion  was  perceptible. 

This  third  or  central  area  was  of  a  dull  yellow,  running  into 
a  dull  brownish  tint,  and  contrasted  strongly  with  the  delicate 
hue  of  the  second  area. 


These  appearances  are  described  as  seen  from  within  the 
cyst  wall. 

That  portion  of  the  cyst  wall  corresponding  to  the  non- 
vascular area  varied  in  thickness,  and  not  nnfrequently  became 
extremely  thin  ;  and  when  the  cyst  ruptures,  it  is  at  <he  poinls 
indicated. 


70  CHALKY    DEPOSIT   IN   CYST   WALLS 

The  further  stage  of  chalky  metamorphosis  is  simply  the 
exchange  of  the  lardaceous  deposit  in  the  tissues  for  that  of 
calcareous  matter — a  condition  quite  distinct  from  that  of  ossi- 
fication. This  chalky  deposit  sometimes  extends  through  a 
large  part  of  the  walls  of  some  of  the  cysts,  and  makes  them 
rough,  uneven,  and  easily  broken.  The  superficial  plastic 
deposits  thrown  out  upon  the  peritoneal  surface  and  its  adhe- 
sions give  a  temporary  respite  from  rupture  in  some  of  these 
cases. 


SIGNS    AND    SYMPTOMS  71 


CHAPTER   II. 

DIAGNOSIS   AND    DIFFERENTIAL    DIAGNOSIS 

Many  of  the  signs  and  symptoms  of  the  ovarian  tumours  classi- 
fied in  the  preceding  chapter  are  common  to  the  whole  group. 
The  outward  manifestations  and  the  inward  effects  are  nearly  the 
same.  There  are  degrees  of  hardness  and  mobility ;  there  are 
shades  of  force  and  sharpness  in  fluctuation ;  there  are  eccen- 
tricities of  form  and  variations  in  relative  position  which  in 
different  cases  alter  the  areas  of  resonance  and  dulness.  But 
the  physical  signs,  though  often  sufficient  for  diagnosis,  are 
sometimes  far  from  conclusive  till  we  come  to  test  the  contents. 
With  them  we  obtain  additional  evidence,  and  are  able  to  de- 
clare in  certain  cases  from  what  sort  of  cyst  they  are  drawn. 

The  symptoms  of  the  tubercular,  and  what  are  called  malig- 
nant tumours,  are  a  set  apart.  With  the  cystic  enlargements, 
simple  and  compound,  there  are  from  the  first  progressive 
uneasiness  running  on  to  distress,  pain  from  nerve  pressure  and 
stretching,  irritation  from  local  congestion,  and  other  effects 
purely  arising  from  mechanical  causes.  But  as  the  tumour 
grows  bigger  and  encroaches  on  the  various  organic  territories, 
functions  are  interfered  with  and  suspended,  the  lines  of  inner- 
vation are  cut  or  compressed,  circulation  and  absorption  are 
interrupted,  nutrition  is  arrested,  and  the  victim  dies  atrophied 
and  suffocated  under  a  veritable  'peine  forte  et  dure.'  The 
evidence  from  mere  symptoms  is  all  along  more  circumstantial 
than  specific,  and  assists  rather  in  forecasting  the  end  than  in 
identifying  any  particular  kind  of  cyst. 

No  time  of  life  is  exempt  from  ovarian  tumours.  They  are 
found  in  infancy  as  well  as  in  extreme  old  age,  though  it  is 
seldom  that  the  development  begins  late.  When  seen  in 
advanced  life  they  are  generally  examples  of  longevity  of  the 
tumour  no  less  than  of  the  person.  The  greater  part  of  my 
patients  have  come  to  me  between  the  ages  of  twenty-five  and 


74  DIAGNOSIS    OF   OVARIAN   TUMOURS 

fifty-live,  and  the  average  age  of  those  on  my  list  of  1,000 
cases  of  completed  ovariotomy  is  as  near  as  may  be  thirty-nine. 
This  would  seem  to  show  clearly  that  the  condition  of  the 
generative  function  has  a  great  deal  to  do  with  the  origin  of 
the  disease.  What  Boinet  says  about  childless  women,  that 
'  sur  500  femmes  atteintes  de  kystes  de  l'ovaire  nous  en  avons 
trouve  390  qui  n'avaient  jamais  eu  d'enfants,'  points  either 
to  a  cause  or  a  consequence,  and  certainly  to  some  connection 
between  the  two  facts. 

It  has  been  said  that  the  ovary  of  the  right  side  is  more 
frequently  affected  than  the  left.  There  is  no  proof  that  it  is 
so,  and  the  statement  is  rather  one  of  impression  than  of 
assurance.  Both  ovaries  are  often  found  diseased  at  the  same 
time  in  different  degrees.  With  this  evidence  of  sequence 
and  with  our  knowledge  of  the  almost  inevitable  correlative 
sympathetic  morbid  action  between  twin  organs  no  question  can 
be  made  as  to  the  rule  of  practice,  as  accepted  in  ophthalmic  sur- 
gery, to  save  one  by  cutting  out  the  other ;  while  it  may  be  as 
wrong  to  cut  out  a  sound  ovary  as  a  healthy  eye. 

A  long  duration  of  the  disease  is  exceptional,  and  race  and 
type  yield  equally  to  the  same  etiologic  influences.  M'Dowell 
soon  fell  upon  cases  among  negresses  as  well  as  whites.  My  list 
is  multicolor  and  cosmopolitan,  and,  if  reports  may  be  trusted, 
ovariotomists  whether  they  date  from  Nova  Zembla  or  New 
Zealand  are  never  in  want  of  subjects. 

DIAGNOSIS   OF   THE    DIFFERENT   KINDS    OF    OVARIAN   TUMOURS   AND 
THEIR    ADHESIONS. 

The  discovery  of  a  tumour  in  the  abdomen  is  generally 
made  by  the  patient  herself.  The  question,  What  is  it? 
is  one  for  the  surgeon.  Having  satisfied  himself  that  he 
has  an  ovarian  tumour  to  deal  with,  and  putting  aside  the 
tuberculous  and  cancerous  degenerations  which  are  indicated  by 
the  general  conditions,  to  him  the  points  of  primary  importance 
are  its  seat,  solidity,  and  relative  freedom.  He  has  to  make  out, 
if  possible,  the  basic  origin  of  this  tumour,  and  what  sort  of 
pedicle  it  has,  on  which  side  it  is  attached,  and  whether  it  be 
single  or  double.  It  is  possible  that  there  may  be  a  cyst  of 
both  ovaries,  one  on  each  side.     This  I  saw  for  the  first  time  in 


DIAGNOSIS    OF    SOLID    TUMOURS  73 

a  young  lady  whom  I  attended  with  Dr.  Priestley.  There  was  a 
distinct  sulcus  between  the  two  cysts  near  the  median  line,  and 
it  became  a  question  whether  this  was  owing  to  disease  on  both 
sides  or  to  the  peculiar  shape  of  a  cyst  on  one  side.  It  was 
supposed  that  the  latter  opinion  was  more  probably  true, 
because  the  catamenia  were  regular ;  but  at  the  operation  two 
free  simple  ovarian  cysts  were  removed  without  difficulty.  In 
one  case  the  appearance  leading  to  suspicion  of  both  ovaries 
being  diseased,  depended  on  a  deep  sulcus  in  the  cyst  caused 
by  the  rotation  of  the  tumour  and  the  pull  on  the  Fallopian 
tube.  If  the  resonance  of  intestine  can  be  distinctly  traced  low 
down  in  front  between  two  cysts,  the  probability  of  ovarian 
disease  on  both  sides  is  strong. 

The  next  questions  are  whether  the  tumour  is  cystic  or 
solid,  or  whether  it  is  free  or  adherent ;  and  if  adherent,  whether 
the  adhesions  are  of  such  a  character  that  they  may  be  sepa- 
rated without  risk,  or  so  extensive  and  intimate  that  separation 
would  be  almost  certainly  fatal.  On  their  solution  depends 
the  decision  whether  tapping  should  or  should  not  be  recom- 
mended according  to  the  probability  of  relief  from  it ;  whether 
drainage  should  be  tried,  or  whether  ovariotomy  would  be 
the  best  practice ;  whether  this  operation  could  be  done 
with  more  or  less  than  the  average  chances  of  a  good  result ; 
or  lastly,  whether  the  difficulties  would  be  so  great  that  it 
should  not  be  attempted  even  if  the  patient  were  herself  anxious 
thereby  to  escape  from  her  sufferings  whatever  the  risk  might  be. 

The  solid  tumours  of  the  ovary  are  excessively  rare.  In  two 
of  the  cases  which  I  have  seen,  the  tumours  were  surrounded  by 
fluid  free  in  the  peritoneal  cavity,  and  it  was  only  after  removal 
of  this  fluid  that  the  size  and  consistence  of  the  hard  body 
could  be  made  out.  Solid  portions  of  large  tumours  which 
fluctuate  in  other  parts  are  common  enough,  but  general  hard- 
ness and  irregularity  of  form,  with  nodular  masses  cartilaginous 
or  bony  to  the  touch,  almost  indicate  the  dermoid  character  of 
the  growth,  especially  in  a  fair  and  young  patient. 

When  by  internal  and  external  examinations  the  outline  of 
the  tumour  can  be  traced  smooth  and  elastic  over  its  whole 
surface  and  extent,  when  the  wave  of  fluctuation  is  equally  per- 
ceptible  in  all  directions  and  sharply  limited  by  the  line  of 
dulness  on   percussion,  and  the  want  of  resonance  is  definitely 


74  DIAGNOSIS   OF   SIMPLE   CYSTS 

circumscribed,  the  inference  is  pretty  clear  not  only  that  the 
tumour  is  cystic,  but  that  it  is  practically  unilocular. 

This  simple  cyst,  however,  may  be  either  ovarian  or  extra- 
ovarian.  If  in  a  young  person  it  is  either  flaccid  and  of  long 
duration,  or  excessively  tense  and  of  recent  formation,  the  infer- 
ence is  almost  equally  clear  that  the  cyst  is  extra-ovarian  and 
the  contents  limpid.  As  this  kind  of  cyst  especially  may  be 
not  only  temporarily  emptied,  but  emptied  with  the  probability 
that  the  fluid  will  not  collect  again,  it  is  interesting  to  ascertain 
if  possible  whether  it  is  really  single  or  whether  there  may  be 
one  large  cyst  with  smaller  ones  concealed.  Two  conditions 
may  be  accepted  as  proof  that  an  extra  ovarian  cyst  is  simple  : 
first,  that  it  has  lasted  for  many  years  with  very  little  damage 
to  the  general  health;  or  secondly,  that  it  has  formed  with 
such  rapidity  as  to  be  almost  certainly  mistaken  for  ascites. 
In  the  first  of  these  two  conditions  the  cyst  is  generally  flaccid, 
and  there  is  little  or  no  suffering  beyond  the  inconvenience 
arising  from  its  bulk.  In  the  second,  the  cyst  is  excessively 
tense,  and  there  is  all  the  suffering  which  accompanies  undue 
and  sudden  abdominal  distension.  Both  are  very  likely  to  be 
pronounced  ascites,  but  may  of  course  be  distinguished  by  the 
signs  of  the  inclosure  of  the  fluid  in  a  cyst,  enumerated  in 
another  part  of  this  chapter. 

With  these  simple  cysts,  whether  of  the  ovary  or  not,  the 
health  is  for  some  time  but  little  affected.  The  first  appear- 
ance is  in  much  the  same  spot,  the  advance  is  similar,  the  form 
of  the  abdomen  and  the  effect  of  change  of  position  are  not 
different.  The  fluctuation  in  both  is  limited,  but  to  the  touch 
the  shock  is  not  the  same.  It  is  as  distinct  in  the  one  as  in 
the  other,  but  from  the  character  of  the  fluid  and  the  thinness 
of  the  walls  in  the  broad  ligament  cysts,  the  wave  impression 
under  percussion  in  them  is  more  defined.  Scarcely  a  trace  of 
these  tumours  can  be  felt  after  tapping,  so  completely  do  the 
walls  collapse.  The  fluid  itself,  in  contrast  with  that  from  an 
ovarian  cyst,  is  thin,  clear,  odourless,  and  any  coagulum  formed 
by  boiling  is  redissolved  by  boiling  acetic  acid.  On  this  test 
the  practitioner  may  mostly  rely  with  safety,  and  found  a 
reasonable  hope  that  further  proceedings  will  be  unnecessary. 

There  are  many  cysts  which,  although  practically  unilocular, 
have  on  some  part  of  the  wall  of  the  mother  cyst,  most  com- 


DIAGNOSIS   OF   MULTILOCULAR   CYSTS  75 

monly  near  the  base,  a  group  or  groups  of  secondary  cysts,  which 
negative  the  supposition  that  the  tumour  is  extra-ovarian,  and 
the  contents  instead  of  being  limpid  will  in  many  instances 
prove  to  be  viscid.  Multilocular  cysts  are  sometimes  as  uniform 
in  outline  as  simple  cysts,  but  as  a  rule  their  surface  is  more  or 
less  irregular  from  the  unequal  development  of  their  component 
parts ;  and  the  projection  of  the  different  compartments  can  be 
both  felt  and  seen.  These  projections  vary  in  hardness,  and 
when  the  resistance  of  the  cyst  wall  to  pressure  is  very  con- 
siderable, when  the  fluctuation  is  limited  by  the  divisions  be- 
tween the  cavities,  and  its  wave  is  slow  and  doubtful,  the  pro- 
bability is  that  the  cyst  wall  is  thick  and  the  contents  colloid. 
A  septum  must  be  very  thin  which  does  not  intercept  the  wave 
of  fluctuation,  but  in  some  cases  of  colloid  tumours,  where  the 
septa  are  imperfect,  the  impulse  of  the  percussed  fluid  is  almost 
as  distinct  and  instantaneous  as  in  a  true  unilocular  cyst. 

Boinet  believes  that  the  colour  and  consistence  of  the  con- 
tents of  multilocular  cysts  may  be  predicted  before  tapping. 
The  progress  of  the  disease,  the  more  or  less  acute  pain,  the 
signs  of  inflammation  more  or  less  acute  and  repeated,  and 
the  state  of  the  general  health,  will  be  sufficient  to  indicate  if 
the  contents  are  serous  or  purulent,  and  what  their  colour  may 
probably  be.  When  abdominal  pains  have  been  frequent,  and 
the  abdomen  is  tender  on  pressure,  it  is  probable  that,  whether 
the  cyst  is  unilocular  or  multilocular,  the  contents  will  be 
reddish,  sero-sanguinolent,  or  resemble  coffee  or  chocolate. 
When  the  temperature  of  the  patient  is  high,  ranging  from 
100°  or  101°  in  the  morning  to  103°  or  104°  at  night,  and 
emaciation  is  progressive,  appetite  lost,  thirst  troublesome, 
sleep  disturbed,  nausea  or  vomiting  distressing,  and  the  ab- 
domen tender  on  pressure,  with  hurried  pulse  and  respiration, 
it  is  extremely  probable  that  one  or  more  of  the  cysts  may 
contain  pus ;  and  that,  when  these  symptoms  are  present  in  an 
extreme  degree,  or  have  lasted  for  a  considerable  period,  the 
pus  has  become  fetid.  Blood  may  be  found  in  one  or  more  of 
the  cysts,  either  as  an  immediate  result  of  twisting  of  the 
pedicle,  or  as  a  more  slow  and  gradual  oozing  from  the  degene- 
rative changes  which  have  been  described. 

When  any  considerable  amount  of  blood  has  been  poured 
into  the  cavity  of  an  ovarian  cyst,  all  the  well-known  signs 


76  DIAGNOSIS   OF   ADHESIONS 

of  internal  haemorrhage  are  necessarily  observed.  I  have 
twice  seen  sudden  death  occur  in  this  way.  In  one  case  five 
pounds  of  blood  and  clot  were  removed  from  the  cyst  into  which 
they  had  been  suddenly  poured  in  consequence  of  the  giving 
way  of  a  large  vein,  which  ran  along  the  lining  membrane  of 
the  cyst.  In  the  second  case  the  blood  passed  into  the  peri- 
toneal cavity.  Another  patient  died,  but  not  immediately,  of 
bleeding  through  the  Fallopian  tube  and  uterus  from  a  large 
cyst  of  the  left  ovary. 

ADHESIONS. 

In  the  early  days  of  ovariotomy  great  pains  were  taken 
to  ascertain  whether  a  tumour  was  free  or  adherent,  and,  if 
extensive  adhesions  to  the  abdominal  wall  were  believed 
to  exist,  ovariotomy  was  considered  to  be  improper  or  im- 
practicable. Mr.  Walne,  in  1843,  began  his  operations  with 
a  small  incision  just  large  enough  to  enable  him  to  ascertain 
with  his  finger  whether  the  cyst  were  free  or  not.  Dr.  Frede- 
rick Bird  published  a  great  number  of  cases  in  which  he  made 
an  exploratory  incision  and  abandoned  the  operation  as  soon  as 
he  found  that  the  adhesions  were  intimate.  He  was  so  anxious 
to  ascertain  the  presence  or  absence  of  adhesions  that,  even 
before  making  an  exploratory  incision,  he  used  to  insert  needles 
through  different  parts  of  the  abdominal  walls  into  the  cyst, 
believing  that  by  watching  the  movements  of  these  needles,  as 
the  patient  inspired  and  expired,  he  could  make  out  whether 
the  cyst  shifted  its  place  beneath  the  abdominal  wall  or  not. 
Others  marked  the  deviations  of  the  canula  after  tapping,  with 
the  same  intention  and  belief,  only  to  find  that  all  these  signs 
were  fallacious.  Before  I  had  operated  on  any  considerable 
number  of  cases,  I  began  to  doubt  whether  cystic  attachments 
seriously  affected  the  result  of  the  operation,  and,  as  soon  as 
the  number  of  the  cases  of  ovariotomy  could  be  reckoned  by 
the  hundred,  it  became  very  clear  that,  although  adhesions  to 
the  abdominal  wall  might  lead  to  some  little  delay  and  difficulty 
in  detaching  the  cyst,  to  some  trouble  in  closing  bleeding 
vessels,  and  to  some  care  in  sponging  out  any  effused  blood 
from  the  peritoneal  cavity,  yet  that  the  statistical  results  were 
absolutely  identical  whether  the  cysts  were  fixed  or  loose. 

Practically,    therefore,    in     deciding    whether    ovariotomy 


ADHESIONS    TO    ABDOMINAL    WALL  77 

should  be  recommended  or  not,  adhesions  to  the  abdominal 
wall  may  be  almost  disregarded.  Still,  it  is  a  matter  of 
some  interest  to  know  what  are  the  signs  by  which  a  free  or 
an  adherent  cyst  may  be  pretty  certainly  recognized.  To  make 
this  examination  the  patient  should  be  placed  in  a  good  light, 
lying  on  her  back,  with  the  shoulders  and  knees  somewhat 
raised,  and  the  whole  abdomen  uncovered.  By  watching  the 
abdominal  movements  during  deep  inspiration  and  full  expira- 
tion, a  free  ovarian  cyst  may  be  seen,  providing  the  abdo- 
minal wall  is  not  too  thick,  moving  upwards  and  downwards 
with  every  breath.  Irregular  elevations  and  depressions  on 
the  surface  of  the  cyst  make  its  free  mobility  perfectly  mani- 
fest and  indubitable ;  but  when  the  surface  is  uniform  it  is 
only  the  upper  border  of  the  cyst  which  can  be  seen  to  move, 
and  to  avoid  deception  it  may  be  necessary  to  ascertain  by  per- 
cussion how  high  the  outline  extends  above  the  umbilicus, 
because  the  transverse  colon,  following  the  respiratory  move- 
ments, may  be  easily  mistaken  for  a  moving  cyst.  A  thick  ab- 
dominal wall  may  obscure  the  movements  of  the  cyst  during 
inspiration  and  expiration,  but  it  is  quite  easy  to  follow  them  by 
the  varying  position  of  the  dull  sound  of  the  cyst  and  the  clear 
sound  of  the  colon  under  percussion. 

The  dull  sound  at  the  upper  boundary  of  the  cyst  will  often 
descend  from  one  to  two  inches  during  inspiration,  and  rise 
during  expiration,  just  as  the  cyst  is  seen  to  move  in  patients 
where  the  abdominal  wall  is  thin.  With  close  adhesions  to  the 
abdominal  wall  no  such  freedom  of  motion  can  be  observed 
nor  is  it  possible.  The  cyst  and  the  abdominal  wall  must  move 
together  unless  the  adhesions  are  loose.  I  have  three  or  four 
times  seen  cases  where  the  cyst  moved  freely  beneath  the  ab- 
dominal wall,  but  in  which  very  firm  adhesions  had  to  be  sepa- 
rated, these  adhesions  consisting  of  flattened  cellular  bands  or 
cords  of  fully  an  inch  in  length.  My  belief  is  that  such  bands 
of  adhesion  have  been  elongated  by  the  free  motion  of  the  cyst 
before  the  lymph  forming  the  connection  had  been  thoroughly 
organised  or  hardened.  Once  aware  of  this  source  of  fallacy,  it 
is  easy  to  check  it  by  placing  the  hands  flatly  over  the  abdomen 
while  the  patient  breathes.  If  the  cyst  be  really  free  no  cre- 
pitus will  be  felt,  whereas  any  long  bands  of  adhesion  give  a. 
sr-nsation  of  grating  or  crackling  to  the  hand,  which  can  only 


78  FRICTION   SOUNDS 

be  mistaken  for  the  rubbing  of  recent  lymph,  or  for  the  pre- 
sence of  omentum  in  front  of  the  cyst.  With  this  sensation  of 
crepitus,  friction  sounds  are  always  audible,  and  the  concur- 
rence was  formerly  supposed  to  be  an  evidence  of  adhesion  by 
lymph  recently  effused  upon  the  peritoneal  surface  of  the  cyst 
or  upon  the  peritoneum  in  apposition  with  the  cyst.  But  this  is 
certainly  an  error.  So  long  as  the  friction  can  be  felt  or  heard, 
movement  must  be  free.  As  soon  as  adhesion  takes  place  fric- 
tion ceases,  and  can  only  be  felt  again  if  the  lymph  which 
forms  the  connecting  medium  becomes  so  stretched  that  motion 
again  becomes  possible  between  the  cyst  and  the  abdominal 
wall.  It  is  quite  common  for  crepitus  to  be  present  for  a  time, 
and  to  disappear  without  any  adhesion,  the  lymph  being  re- 
moved and  the  surface  of  the  peritoneum  again  rendered 
smooth.  The  crepitus  which  is  produced  by  the  presence  of 
omentum  between  the  cyst  and  the  abdominal  wall  may  be 
mistaken  for  that  caused  by  recent  lymph  or  old  stretched 
adhesions,  but  it  is  not  impossible  to  distinguish  them  with 
tolerable  certainty.  With  omentum  there  is  a  softer  and  more 
doughy  feel,  and  it  is  seldom  present  over  any  part  of  a  cyst 
not  near  some  intestine.  This  is  easily  recognized  by  its 
resonance  on  percussion  and  its  gurgling  under  pressure, 
and  there  is  neither  the  tenderness  nor  general  feverishness 
which  accompany  the  recent  effusion  of  lymph. 

This  interesting  point  in  the  diagnosis  of  adhesions  presented 
itself  in  the  case  of  an  unmarried  girl,  eighteen  years  of  age, 
sent  to  me  some  years  ago  by  Dr.  Whitehead,  of  Manchester. 
Her  tumour,  which  had  not  been  tapped,  was  observed  to  move 
very  freely  beneath  the  abdominal  parietes  on  deep  inspiration, 
and  I  therefore  expected  to  find  it  non-adherent.  But  at  the 
operation  on  June  13,  1864,  very  firm  adhesions  anteriorly  and 
in  the  right  iliac  fossa,  sufficiently  long  to  admit  of  the  cyst 
moving  freely,  and  a  very  extensive  surface  of  adherent 
omentum,  were  separated  by  the  hand  with  some  difficulty, 
and  a  close  adhesion  to  the  fundus  of  the  bladder  required 
careful  dissection. 

The  action  of  the  recti  abdominales  varies  with  the  different 
conditions  of  ovarian  tumours,  and  should  be  brought  into  view 
by  directing  the  recumbent  patient  to  try  and  sit  up  without 
assisting  herself  by  her  hands  or  elbows.     This  effort  puts  the 


PELVIC    ADHESIONS  79 

recti  upon  the  stretch,  and  if  a  tense  ovarian  cyst  is  free  from 
adhesion,  it  falls  backwards  and  to  the  sides,  while  the  muscles 
form  a  projecting  ridge  in  the  centre  of  the  abdomen.  The 
same  appearance  is  seen  in  cases  of  adherent  cyst  only  when  it 
is  flaccid  or  partially  empty. 

The  umbilicus  is  not  affected  by  the  movements  of  a  free 
ovarian  cyst  during  respiratory  action,  or  when  pushed  in 
various  directions.  But  any  movement  communicated  to  a 
cyst  which  adheres  to  the  front  of  the  abdominal  wall  is 
immediately  followed  by  a  corresponding  movement  of  the  navel. 

But  while  adhesions  to  the  abdominal  wall  are  less 
regarded  in  ovariotomy,  adhesions  low  down  in  the  pelvis  are 
on  the  contrary  of  great  importance.  The  difficulty  is  to 
separate  them  without  serious  injury  to  the  rectum  or  the 
bladder,  or  the  ureters,  or  to  large  blood-vessels  or  to  nerves, 
and  it  is  not  easy  to  find  every  bleeding  vessel  or  to  stop  the 
loss  of  blood.  When  deep  seated  and  very  intimate,  the  dissec- 
tion necessary  is  out  of  the  question  in  the  living  patient  and 
gives  no  small  trouble  after  death.  Such  a  condition  may  be 
always  suspected  or  rendered  almost  evident,  especially  after 
tapping,  when  placing  the  patient  on  her  elbows  and  knees, 
with  the  pelvis  raised  and  the  thorax  depressed,  the  lower 
portion  of  the  tumour  can  be  felt  unyielding  by  the  finger 
through  the  vagina  or  rectum,  and  the  uterus  is  found  either 
pulled  up  out  of  reach  or  pressed  backwards  or  forwards  or  to 
either  side  while  its  mobility  is  considerably  restricted. 

But  it  is  quite  possible  that  the  lower  portion  of  on  ovarian 
tumour  may  be  jammed  downwards  and  moulded  into  the 
pelvis  without  becoming  attached.  Then  in  the  same  position 
some  force  with  the  finger  will  dislodge  it  and  show  that  it  is 
not  bound  down  by  adhesions.  I  have  operated  on  an  ovarian 
tumour  thus  simply  impacted  in  Douglas's  space  with  the  uterus 
thrust  upwards  out  of  the  pelvis.  Both  ovaries  were  diseased, 
and  though  there  were  no  adhesions  one  cyst  was  prevented  from 
rising  by  the  other.  They  were  successfully  removed.  It  is 
curious  in  such  cases  to  hear  the  rush  of  air  into  the  hollow  when 
the  lower  portion  of  the  cyst  is  pulled  away  from  the  sacrum. 
The  air  passes  down  with  a  gurgling  sound,  and  the  tumour  is 
brought  away  with  no  more  than  the  ordinary  difficulty. 

Adhesions  to  the  liver,   stomach,  or  spleen  can  never  be 


80  DIFFERENTIAL    DIAGNOSIS    OF 

accurately  made  out  before  operation.  Sometimes  a  coil  of 
intestine  can  be  distinctly  traced,  always  remaining  attached 
to  the  same  part  of  the  cyst  wall.  Further  than  this,  adhesions 
to  the  abdominal  viscera  can  only  be  ascertained  after  the  ope- 
ration has  been  commenced. 

DIFFERENTIAL   DIAGNOSIS   OF   OVARIAN   TUMOURS. 

When  a  woman  with  enlarged  abdomen  comes  under  medical 
examination,  the  three  inevitable  questions  rise  up  for  determi- 
nation: 1st.  Has  she  an  ovarian  tumour,  or  is  it  something 
else  which  can  give  rise  to  the  same  symptoms  and  appearances  ? 
2nd.  If  she  has  an  ovarian  tumour,  of  what  kind  is  it,  and 
how  can  we  distinguish  one  kind  from  another  ?  and  3rd.  Are 
there  any  other  abdominal  conditions  and  diseases  of  enlarge- 
ment coexisting  with  it  and  disguising  its  identity,  modifying 
its  progress,  or  influencing  our  views  as  to  its  treatment  ? 

The  first  point  therefore  which  has  to  be  considered  in 
studying  a  case  of  abdominal  swelling,  is  the  organ  from  which 
it  arises.  The  presumption  being  on  the  side  of  an  ovarian 
tumour  from  the  existence  of  a  certain  set  of  signs  and  symp- 
toms, the  probability  of  its  being  simulated  by  some  other 
disease  has  to  be  discussed.  And  there  are  many  conditions, 
some  morbid,  others  natural,  which  may  give  rise  to  doubt  and 
difficulty  in  coming  to  a  decision ;  though  these  diagnostic 
puzzles  vary  much  in  force  according  to  their  nature,  the  con- 
ditions under  which  they  offer  themselves,  and  the  amount  of 
experience  and  tact  in  the  investigator. 

After  the  following  enumeration  of  the  principal  states  and 
diseases  which  may  throw  doubt  on  the  diagnosis  of  a  case 
of  ovarian  tumour,  or  for  which  it  may  be  mistaken,  I  shall 
proceed  to  the  separate  consideration  of  the  most  important. 
In  connection  with  the  peritoneum  we  have — 

Ascites, 

Encysted  dropsy  of  the  peritoneum, 

Tympanites  and  phantom  tumours, 

Fibro-plastic  tumours  of  peritoneum, 

Fatty  tumours  of  omentum  and  mesentery, 

Hydatids, 

Cancer  and  tubercle. 


OVARIAN    TUMOURS  81 

Difficulties  in  diagnosis  caused  by  uterine  enlargements  arise 
from — 

Pregnancy, 

Ketained  menses  and  moles, 

Air  and  fluids  in  uterus, 

Fibroid  tumours, 

Cancer. 

Another  miscellaneous  group  is  this — 

Hypertrophy  of  the  abdominal  wall, 

Enlargements  of  other  viscera,  such  as  the  liver,  spleen, 
and  lumbar  and  mesenteric  glands, 

Hydatid  cysts  of  the  liver,  gall-stones, 

Movable  kidney  and  cysts  of  the  kidney, 

Faecal  accumulations, 

Distended  bladder, 

Hsematocele, 

Pelvic  abscess, 

Extra-uterine  pregnancy, 

Enchondroma,  or  encephaioid  disease  of  ilium  or  ver- 
tebrae. 

Many  of  the  evils  and  discomforts  which  accompany 
the  progress  of  a  case  of  ovarian  tumour  arise  no  doubt 
from  its  mere  mechanical  interference  with  the  organs  in 
the  chest,  pelvis,  and  abdomen — displacing  and  compressing 
them,  impairing  their  nutrition,  and  disturbing  their  functions. 
But  the  pressure  of  the  gravid  uterus  is  as  great,  or  even 
greater,  and  a  woman  in  pregnancy  has  sometimes  to  endure 
annoyances  or  even  real  miseries.  Still  the  process  is  natural, 
and  there  are  compensations  in  the  shape  of  local  adjustments, 
and  temporary  accommodating  changes  of  form,  and  mental 
considerations,  and  moral  influences,  which  are  wanting  to  the 
victim  of  ovarian  disease.  Instead  of  being  cheered  by  the 
hopes  and  aspirations  of  maternity,  she  has  to  bear  the  torture 
of  suspense  or  despair;  her  blood  is  impoverished,  and  her 
nervous  system  shattered  by  imperfect  assimilation  ;  and  one  is 
justified  in  more  than  suspecting  a  local  protesting  resistance 
to  the  growth  of  the  invading  tumour.  After  a  time,  the 
emaciation,  always  going  on,  and    the  weary,   ceaseless    self- 

G 


82 


PHYSIOGNOMY 


watchings,  made  inevitable  by  the  incapacity  to  use  healthful 
exercise  or  to  undertake  the  usual  occupations  with  success, 
chisel  out  the  features  into  the  peculiar  pinched  expression 
which  has  been  described  as  the  fades  uterina,  but  which 
would  probably  be  better  named  fades  ovariana. 

The  drawing,  which  is  an  exact  copy  of  a  photographic 
portrait  (by  Dr.  Wright),  gives  a  very  correct  idea  of  this 
peculiar  physiognomy.  The  emaciation,  the  prominent  or 
almost  uncovered  muscles  and  bones,  the  expression  of  anxiety 
and  suffering,  the  furrowed  forehead  (not  sufficiently  marked  in 


r,  n 


the  drawing),  the  sunken  eyes,  the  open,  sharply  denned 
nostrils,  the  long  compressed  lips,  the  depressed  angles  of  the 
mouth,  and  the  deep  wrinkles  curving  round  these  angles, 
form  together  a  face  which  is  strikingly  characteristic. 

The  tumour  begins  to  grow  on  one  side,  where  it  occupies 
space  wanted  for  the  large  intestine  with  its  accumulations, 
and  no  provision  is  made,  as  for  the  uterus,  for  its  expansion 
or  for  the  due  maintenance  of  its  relative  position  in  respect  to 
the  viscera.  All  is  irregular  and  wrong.  At  first  the  weight 
makes  it  settle  down  into  the  pelvis,  where  it  causes  irritation 


LOCAL  EFFECTS  OF  OVARIAN  TUMOURS 


83 


of  the  bladder  and  rectum.  Mounting  higher  with  augmenting 
bulk,  the  large  intestine,  according  to  side,  gets  jammed,  and 
the  fsecal  matter  impacted;  the  uterus  is  displaced,  thrust  down, 
or  to  one  or  the  other  side,  retroverted  or  anteverted  ;  and,  as 
the  case  advances,  is  sometimes  dragged  up  by  its  attachments 
so  as  to  be  out  of  reach  of  the  finger  in  the  vagina.  Its  form 
is  distorted,  and  its  functions  rendered  difficult  and  painful, 


though  not  absolutely  impossible ;  for,  as  it  has  been  already 
seen,  there  are  many  coincident  cases  of  even  successful  preg- 
nancy. The  urinary  organs  seldom  escape  at  any  stage  of  the 
disease.  When  the  pressure  is  on  the  bladder,  micturition  in 
either  troublesome,  impossible,  or  distressingly  urgent.  With 
strain  upon  or  pinching  of  the  ureters,  there  may  be  stoppage 
of  the  flow  of  urine,  or  suspension  of  its  secretion,  or  poisonous 
reflux  into  the  system.  Even  the  kidneys  may  be  flattened 
and  almost  annihilated.  The  vital  organs  in  the  chest  suffer 
in  many  ways,  and  the  chest  symptoms  of  oppressed  action 
ire  often  among  the  most  tormenting.     (Edema,  ascites,  and 

.1  2 


84 


LOCAL    EFFECTS    OF   OVARIAN   TUMOURS 


pleural  effusion,  especially  on  the  right  side,  occasion  the 
greatest  aggravation  of  misery ;  and  the  effects  of  distension 
upon  the  ribs  and  spine  are  so  opposed  to  readjustment  as  to 
amount  to  serious  hindrance  to  recovery  after  tapping.  More 
than  once  the  ribs,  which  have  been  thrown  out  like  a  fan,  with 
the  intercostal  structures  overstretched,  have  never  returned 
to  their  normal  condition  ;  the  lungs,  which  have  been  confined 
to  a  very  small  space,  had  so  far  lost  their  resiliency  that  air 
could  not  easily  expand  them  again ;  or  the  pleural  cavities, 
filled  with  fluid,  have  not  been  freed  by  absorption,  or  the 
lung  has  not  expanded  after  tapping,  and  the  patient  has  died 
from  want  of  breathing  power.  Occasionally  the  same  diffi- 
culty has  been  met  with  after  ovariotomy,  and  a  patient  in 
whom  repair  has  gone  on  well  so  far  as  the  abdomen  was  con- 
cerned has  had  her  recovery  greatly  retarded,  or  has  died 
simply  in  consequence  of  the  state  of  her  chest.  The  two 
accompanying  copies  of  photographic  portraits  show  well  how 
limited  the  breathing  space  sometimes  becomes  in  consequence 
of  the  excessive  growth  of  the  tumours. 


**  '  i         .      ; 


DIAGNOSIS   BETWEEN   OVARIAN    DROPSY   AND   ASCITES. 


Our  senses  of  sight,  touch,  and  hearing  are  all  required  to 
assist  us  in  distinguishing  ascites    from    ovarian    dropsy,    the 


DIAGNOSIS   BY    INSPECTION 


85 


physical  diagnosis  being  established — 1,  by  inspection  and 
measurement ;  2,  by  palpation ;  3,  by  percussion  and  auscul- 
tation ;  and  4,  by  chemical  and  microscopical  examination  of 
the  fluids. 

I.  Inspection. — The  size  of  the  abdomen  is  seen  to  be  in- 
creased both  in  ascites  and  in  ovarian  dropsy;  and,  when  an 
ovarian  cyst  is  large,  the  abdominal  enlargement  is  general,  as 
it  is  in  ascites.  But  while  the  cyst  is  of  moderate  size,  the 
abdominal  enlargement  is  often  partial,  more  to  one  side  than 
the  other,  more  below  the  umbilicus  than  above. 

In  form,  the  flanks  and  sides  of  the  abdomen  protrude  in 
ascites,  the  front  not  being  more  convex  than  in  the  natural 


state,  or  it  may  be  flattened :  while  in  ovarian  disease  the  bulg- 
ing is  generally  most  evident  in  front,  less  so  at  the  sides, 
and  often  more  on  one  side  than  the  other.  When  the  differ- 
ent portions  of  a  multilocular  cyst  can  be  seen,  of  course  all 
doubt  is  dispelled,  but  these  remarks  apply  to  simple  cysts 
only.  Alterations  in  position  generally  produce  a  greater  and 
more  immediate  change  in  the  form  of  the  abdomen  in  ascites 
than  in  ovarian  disease,  the  free  fluid  gravitating  much  more 
readily  than  a  cyst  can  move.  The  normal  depression  of  the 
umbilic'LCS  is  altered  whenever  the  general  abdominal  enlarge- 
ment is  considerable  both  in  ascites  and  ovarian  dropsy  ;  but 
in  the  latter  disease,  although  it  may  be  flattened  as  in  pieg- 


86  DIAGNOSIS   BY   INSPECTION 

nancy,  it  is  only  prominent  and  bulging  as  it  very  often  is  in 
ascites,  or  when  ascitic  fluid  surrounds  an  ovarian  tumour,  or 
when  there  is  an  ordinary  umbilical  hernia  also.  The  super- 
ficial veins  may  be  dilated  from  the  lower  part  of  the  abdomen 
to  the  chest,  on  one  or  both  sides,  in  either  disease.  This  vari- 
cose state  of  the  veins  only  assists  in  diagnosis  when  much 
more  evident  on  one  side  than  the  other.  Such  undue  import- 
ance has  been  given  to  this  vascular  condition  as  a  distinction 
between  ascites  and  ovarian  dropsy,  and  between  simple  and 
malignant  tumours  within  the  abdomen,  that  the  following 
facts  should  be  recollected  : — 

The  appearance  of  congestion  of  the  epigastric  veins,  seen 
merely  as  a  fine  network  of  capillaries,  is  usually  a  simple  result 
of  absorption  of  the  cutaneous  fat,  the  vessels  becoming  visible 
through  the  thinned  and  distended  skin,  and  has  no  diagnostic 
value.  When  some  of  the  larger  veins,  distended  or  varicose, 
in  their  course  from  the  inguinal  region  upwards,  either  cease 
abruptly  in  the  middle  of  the  abdomen,  or  run  to  the  hypo- 
chondriac region,  or  even  up  to  the  clavicles,  anastomosing  with 
branches  of  the  mammary  and  intercostal  veins,  the  impedi- 
ment to  the  circulation  may  be  of  several  kinds.  It  may  be 
either  in  the  heart,  the  trunk  or  larger  branches  of  the  inferior 
cava,  or  in  the  Portal  system.  Pregnancy,  tumours,  or  coagula 
causing  obstruction  in  any  of  these  vessels  will  throw  the 
circulation  into  the  epigastrics. 

When  the  integuments  are  cedematous,  the  linese  albicantes 
become  more  prominent  than  the  neighbouring  portions  of 
skin,  and  have  a  knotty  appearance,  which  has  led  to  the  mis- 
taken appellation  of  varicose  lymphatics.  I  have  observed  it 
chiefly  in  cases  of  tumour  surrounded  by  ascitic  fluid. 

The  movement  on  respiration  is  defective,  both  as  regards 
the  soft  wall  of  the  abdomen  and  the  lower  ribs  ;  while  that  of 
the  upper  ribs  is  exaggerated  in  both  diseases.  The  alteration  in 
movement  only  assists  in  diagnosis  when  it  is  partial  or  affects 
only  one  side.  On  making  deep  inspirations  the  upper  part  of 
an  ovarian  cyst  may  often  be  seen  to  rise  and  fall.  This  ap- 
pearance is  very  characteristic.  In  ascites  it  may  be  simulated 
by  some  distended  coils  of  intestine  moving  with  the  diaphragm ; 
but  the  resonance  of  the  intestine  on  percussion  instantly 
settles  all  doubt  on  this  point. 


PALPATION   IN    OVARIAN    DISEASE  87 

On  measurement,  the  enlargement  of  the  abdomen  in 
ordinary  ascites  is  equal  on  both  sides,  or  symmetrical;  and, 
although  the  distance  from  the  sternum  to  the  pubes  is  in- 
creased, the  umbilicus  retains  its  normal  position — about  an 
inch  nearer  to  the  pubes  than  to  the  sternum — and  is  about 
on  a  level  with  the  highest  point  of  the  crest  of  the  ilium  on 
each  side,  and  midway  between  these  two  points.  In  ovarian 
dropsy  there  is  often  a  considerable  alteration  in  the  measure- 
ments between  the  umbilicus  and  sternum,  and  umbilicus  and 
pubes,  as  well  as  between  the  umbilicus  and  the  two  crista? 
ilii.  In  ascites  the  greatest  circular  measurement  is  at  the 
level  of  the  umbilicus ;  in  ovarian  dropsy  it  is  often  some 
inches  lower  down. 

II.  On  palpation,  the  abdominal  wall  is  felt  to  be  harder 
and  more  resistant  than  natural  in  both  diseases  in  the  parts 
made  tense  by  much  fluid,  but  is  soft  and  elastic  elsewhere. 
Consequently  the  variation  in  the  seat  of  hardness  with  the 
position  of  the  patient  becomes  useful  in  diagnosis,  the  fluid  in 
ascites  gravitating  freely  to  the  most  dependent  part.  Fluc- 
tuation is  perceived  with  varying  distinctness  according  to  the 
degree  of  tension  of  the  abdominal  wall,  to  the  thickness  of  the 
layer  of  fat,  to  the  amount  of  oedema,  to  the  thickness  of  the 
peritoneum  or  of  the  cyst,  to  the  quantity  and  character  of 
the  fluid,  and  to  the  amount  of  tympanitic  distension  of  the 
intestines.  It  occasionally  happens  that  the  abdomen  is  too 
forcibly  distended  to  respond  to  the  stroke,  and  gives  no  sign 
of  fluctuation.  In  itself,  it  offers  no  assistance  in  diagnosis, 
because  a  thin-walled  ovarian  cyst,  filled  with  limpid  fluid, 
with  a  moderately  tense  and  thin  abdominal  wall,  would  give 
a  more  quick  and  decided  wave  than  a  moderate  quantity  of 
ascitic  fluid  beneath  an  abdominal  wall  thickened  by  fat  or 
subcutaneous  oedema.  The  characteristic  peculiarity  of  the 
fluctuation  in  ascites  is  that  it  varies  with  the  position  of  the 
patient,  and  is  only  perceived  in  the  parts  where  the  fluid 
gravitates  towards  the  abdominal  wall ;  while  in  ovarian  dropsy 
its  situation  does  not  vary  with  position,  but  is  perceived 
wherever  fluid  is  to  be  discovered  by  percussion. 

III.  Percussion  and  auscultation. — The  two  following 
'H;igrams  represent  the  situation  of  clear  and  dull  sounds 
obtained  by  percussion  in  typical  cases  of  ascites  and  ovarian 


88 


rERCUSSION    IN   OVAIUAN    DISEASE 


disease,  the  patient  lying  flat  and  evenly  on  her  back.  The 
dark  parts  of  the  abdomen  are  dull,  the  rest  clear.  In  ascites, 
the  stomach  and  intestines  are  above  and  in  front;  the  fluid, 
behind  and  on  either  side.  In  ovarian  dropsy  the  fluid  is  in 
front,  extending  in  different  degrees  to  either  side,  and  push- 
ing the  stomach  and  intestines  upwards  and  backwards,  just  as 
a  gravid  uterus  does.  The  figure  to  the  right  of  the  page, 
indeed,  would  represent  either  a  gravid  uterus  near  the  full 
period  of  pregnancy,  or  an  ovarian  cyst  of  about  the  size  of 
such  a  uterus,  and  situated  centrally,  as  ovarian  cysts  often  are 
at  this,  or  a  rather  later,  period  of  their  growth.  But  quite  as 
frequently  they  tend  towards  one  side  or  the  other,  in  such 
cases  the  diagnosis  being,  of  course,  easier. 


It  is  seldom  that  a  patient  with  ascites  lies  so  flat  as  not  to 
raise  the  shoulders  enough  to  throw  a  layer  of  fluid  downwards 
towards  the  pubes.  Very  often  the  dulness  may  extend  as 
high  as  the  umbilicus,  and  it  generally  does  so  when  the 
shoulders  are  much  raised  by  pillows.  This  might  lead  a 
superficial  observer  to  suppose  that  the  disease  was  ovarian, 
because  there  was  a  dull  sound  in  the  front  of  the  abdomen  ; 
but  on  lowering  the  shoulders  and  placing  a  pillow  or  hassock 
under  the  hips,  the  fluid  at  once  gravitates  towards  the  dia- 
phragm, the  intestines  float  to  the  surface,  and  a  clear  sound  is 
obtained  where  it  was  dull  before.  No  such  alteration  in  the 
situation  of  dulness  can  possibly  occur  in  ovarian  disease.  So 
on  turning  from  side  to  side,  the  fluid  flows  over  to  the  side 
which  is  low,  and  the  intestines  rise  to  the  upper  side,  with 


AUSCULTATION  89 

corresponding  changes  in  the  situation  of  dull  and  clear  sounds 
on  percussion.  This  does  not  take  place  in  ovarian  disease. 
Again,  at  any  spot  near  the  level  where  the  resonance  of  the 
intestines  ends,  and  the  dulness  of  the  fluid  begins,  and  a  dull 
sound  is  elicited  by  gentle  pressure  and  percussion,  a  deeper 
pressure  will  displace  the  fluid,  and  the  resonance  of  the  in- 
testines will  be  again  heard.  At  the  most  depending  spots  the 
amount  of  pressure  necessary  to  obtain  a  clear  sound  is  some 
guide  to  the  estimation  of  the -thickness  of  the  layer  of  fluid. 
Superficial  and  deep  percussion  cannot  produce  such  difference 
in  the  sounds  in  ovarian  disease. 

When  fluid  is  free  in  the  peritoneal  cavity  the  wave  of 
fluctuation  may  be  felt  not  only  where  the  sound  is  dull  on 
percussion,  but  also  beyond  the  line  of  dulness,  even  where 
resonance  may  be  tympanitic.  The  intestines  float  in  the 
fluid,  and  the  fluid  may  be  thrown  in  waves  among  them.  But 
when  fluid  is  contained  within  a  cyst,  fluctuation  cannot  be 
detected  beyond  the  boundaries  of  the  cyst.  Hence  the  out- 
line of  the  cyst,  traceable  by  dulness  on  percussion,  and  the 
line  where  fluctuation  can  be  perceived  must  be  the  same.  The 
wave  of  fluctuation  ends  at  the  limit  of  resonance. 

It  has  been  supposed  that  percussion  on  the  loins  is  a  very 
sure  guide  in  diagnosis — that  when  the  patient  is  sitting  up, 
and  one  loin  is  clear  and  the  other  dull,  the  disease  is  ovarian, 
but  that  when  there  is  dulness  on  both  sides  it  is  ascites. 
One  dull  side  is  also  supposed  to  be  a  proof  that  the  ovary  of 
that  side  is  the  one  diseased.  But  there  are  so  many  excep- 
tions to  these  rules,  that  they  are  of  no  great  value,  except  as 
corroborating  or  counterbalancing  other  physical  signs. 

Auscultation  alone  affords  little  information,  but  it  shows  the 
presence  of  the  gurgling  sounds  of  the  intestines  in  the  spots 
clear  on  percussion,  and  the  absence  of  these  sounds  in  the 
dull  spots,  except  on  deep  pressure  by  the  stethoscope.  In 
both  diseases  the  fluctuation  wave  of  fluid  may  be  heard  as 
well  as  felt.  The  aortic  sounds  and  impulse  are  transmitted  by 
the  cystic  and  solid  tumours,  but  not  by  ascites. 

By  applying  these  general  rules  a  few  seconds  will  enable 
the  surgeon  to  clear  up  all  doubt  in  any  ordinary  case.  But 
there  are  various  conditions  which  may  lead  to  the  necessity 
for  further  examination.     The  quantity  of  fluid  in  the  perito- 


90  CHEMICAL   AND   MICROSCOPICAL  EXAMINATION 

neal  cavity  may  be  so  large  that  the  front  of  the  abdomen  is 
pushed  far  beyond  the  reach  of  the  intestines.  They  float  as 
far  as  the  mesentery  will  allow  them,  but  cannot  reach  the 
surface  of  the  abdominal  wall.  In  this  case  percussion  must 
give  a  dull  note  in  front  just  as  it  does  in  ovarian  dropsy.  So 
when  the  intestines  are  fixed  in  the  back  part  of  the  abdomen 
by  adhesions,  or  by  a  thickened  omentum,  the  fluid  is  kept  to 
the  front  as  in  ovarian  dropsy. 

Or  an  ovarian  cyst  may  contain  air  or  gas,  either  from  a 
perforating  communication  with  intestine,  or  through  the  Fallo- 
pian tube,  or  after  tapping  and  decomposition  of  fluid.  Per- 
cussion then  gives  a  clear  note  in  front  or  above,  and  a  dull 
note  behind  or  below,  as  it  does  in  ascites ;  and  occasionally, 
where  there  is  a  mixture  of  air  with  fluid,  the  sound  so  well 
known  as  metallic  tinkling  may  be  heard — air  bubbling  through 
fluid — or  drops  of  fluid  falling  in  the  cavity.  In  these  circum- 
stances physical  diagnosis  alone  cannot  solve  the  doubt,  and  we 
have  to  consider  all  that  can  be  learned  from  the  history  of  the 
case  and  the  general  condition  of  the  patient.  So,  when  fluid 
is  free  in  the  peritoneal  cavity  we  must  resort  to  tapping  and 
chemical  or  microscopical  investigation  before  we  can  decide 
whether  the  fluid  is  the  ordinary  non-inflammatory  serum 
which  transudes  into  the  cavity  in  heart,  liver,  or  kidney  disease, 
or  the  inflammatory  exudation  of  chronic  peritonitis  in  its 
simple  or  its  tubercular  or  cancerous  form,  or  whether  it  may  be 
ovarian  fluid  which  has  escaped  from  a  perforated  or  ruptured 
cyst. 

IV.  Chemical  and  microscopical  examination  of  the  fluids. 
— The  normal  Graafian  follicle  of  the  healthy  ovary  contains 
a  minute  quantity  of  a  slightly  viscid,  whitish  yellow,  albumi- 
nous fluid  resembling  the  serum  of  blood.  It  is  alkaline,  of 
pale  whitish  yellow  colour,  and  transparent.  It  is  not  ropy 
but  limpid,  readily  separating  into  minute  drops.  It  con- 
tains a  small  quantity  of  a  substance  which  will  coagulate 
when  treated  with  acids  or  alcohol,  or  when  exposed  to  a  raised 
temperature.  It  holds  in  suspension  spheroidal,  nucleated  epi- 
thelial cells  and  shreds  of  epithelium  from  the  membrana 
granulosa  of  the  ovisac.  These  nuclei  and  cells,  which  are 
spheroidal  in  the  human  female,  are  prismatic  in  certain  classes 
of  animals.     In  the  rodents  ciliated  epithelium  will  be  found, 


CONTENTS  OF  OVARIAN  CYSTS  91 

although  only  a  small  number  of  the  cells  possess  vibrating  cilia. 
In  the  human  female,  even  in  the  normal  condition,  these  cells 
occasionally  become  granular,  and  filled  with  fatty  granules. 
When  this  is  the  case,  they  appear  much  darker  than  the  sur- 
rounding non-granular  cells. 

After  the  rupture  of  the  ovisac  it  would  appear  that  the 
fluid  contents,  or  '  ovarine,'  escape  into  the  peritoneal  cavity ; 
but  the  quantity  is  so  minute  that  it  can  hardly  do  more  than 
moisten  the  fringes  of  the  Fallopian  tube.  There  is  not  enough 
to  penetrate  far  into  the  tube. 

There  are  endless  differences  in  the  contents  of  ovarian 
cysts,  and  these  differences  seem  to  be  in  no  way  dependent 
on  the  form  of  the  cysts  or  the  anatomical  arrangement  of  their 
tissues.  Even  the  many  strange  epithelial  developments  are 
not  accompanied  by  any  special  kind  of  fluid.  In  the  simple 
unilocular  cysts,  it  is  most  common  to  find  a  perfectly  clear, 
hyaline,  colourless,  pale  yellow,  or  straw-coloured  fluid.  But  it 
is  not  always  so,  for  all  gradations  of  colour  and  thickness  occur, 
and  epithelial  cells  or  scales  are  almost  always  floating  in  the 
fluids.  In  some  rare  cases  there  are  cholesterine  crystals  which, 
after  standing,  form  a  glittering  pellicle  on  the  surface.  But 
although  the  quantity  is  really  very  small,  it  is  so  very  rarely 
met  with  in  ascitic  fluid,  that  it  may  almost  be  looked  upon  as 
diagnostic  of  the  others.  True  albumen  may  be  present,  but 
in  very  uncertain  proportions.  It  is  in  the  few  cases  where 
it  is  absolutely  wanting  that  simple  tapping  proves  curative. 
Spontaneously  coagulable  fibrine  is  hardly  ever  a  constituent  of 
the  simple  cystic  fluids,  a  character  which  distinguishes  them 
from  ascitic  effusions,  from  which  there  is  almost  invariably  a 
deposit  of  fibrine  taking  the  form  of  elastic  filaments  after 
washing ;  the  deposit  from  ovarian  serum,  if  any,  being  soft 
and  not  at  all  elastic.  Ascitic  fluids  never  contain  more  solid 
matter  than  the  serum  of  the  blood,  and  the  greater  number  of 
ovarian  fluids  have  even  less  ;  but  any  serous  fluid  taken  from 
the  abdomen  of  a  woman  which,  when  filtered,  leaves  after 
evaporation  a  dry  residue  in  excess  of  that  which  would  be 
found  in  blood  serum,  may  be  pronounced  upon  as  positively 
ovarian.  Pus  and  blood  are  seen  in  different  conditions;  in 
some  cysts  they  are  mixed  with  the  clearer  fluid,  and  allowance 
must  be  made  for  them  in  chemical  investigations.     Among 


92  COMPOSITION    OF 

the  many  cysts  of  a  compound  tumour,  some  may  be  seen  with 
almost  pure  serum,  and  after  tapping  others  may  contain  pus 
and  offensive  gases.  Blood  often  mixes  with  the  other  con- 
tents, and  influences  the  colour  as  well  as  other  qualities.  The 
yellow,  green,  brownish,  or  red  tints  depend  upon  the  presence 
of  bile  acids  or  the  admixture  of  blood  and  pus,  which  may  be 
recent  and  pure,  or  old  and  undergoing  changes.  The  turbidity 
of  the  fluid  generally  depends  on  the  admixture  of  these 
secondary  matters.  Blood  is  not  unfrequently  effused  into  the 
smaller  cysts,  where  it  sometimes  becomes  fibrillated  and  par- 
tially organised,  though  it  more  frequently  runs  into  a  state  of 
decomposition. 

Since  Scherer's  discovery  of  paralbumen,  and  the  subsequent 
discovery  that  this  derivative  or  altered  form  of  albumen  proper 
is  a  chief  ingredient  in  ovarian  fluids,  it  was  at  first  believed 
that  it  would  be  a  sure  means  of  distinguishing  these  from  all 
other  fluids  in  abdominal  swellings.  But  later  experience  has 
proved  that  this  test  alone  is  unreliable.  The  presence  of 
paralbumen  is  certainly  not  a  positive  sign  that  fluid  has  come 
from  an  ovarian  cyst.  Dr.  Schetelig  found  the  contents  of  a 
very  large  renal  cyst,  which  he  had  emptied,  to  consist  mainly 
of  paralbumen  with  cholesterine,  and  there  was  no  trace  of  urea, 
the  proper  kidney  structure  having  been  completely  annihilated. 
But  Scherer  also  pointed  out  the  relations  of  metalbumen  to 
mucin,  which,  he  says,  colloid  matter  always  contains  in  con- 
siderable quantity ;  and  he  also  raised  the  question  whether 
metalbumen  ought  not  to  be  considered  as  a  transition  state 
between  albumen  and  mucin  or  colloid  matter.  Paralbumen 
and  metalbumen  are  forms  of  albumen  which  differ  from  the 
true  albumen  in  that  they  are  soluble  in  boiling  acetic  acid. 
You  take  a  test  tube  and  boil  the  ovarian  fluid ;  the  albumen  is 
coagulated.  You  add  double  the  volume  of  strong  acetic  acid  to 
the  coagulum,  boil,  and  shake  it ;  when,  if  the  albumen  be  true, 
the  coagulum  does  not  redissolve  in  the  acetic  acid.  But  sup- 
posing it  to  be  paralbumen,  or  metalbumen,  then  it  either  dis- 
solves or  forms  a  whitish  transparent  fluid,  or  breaks  up  into  a 
kind  of  jelly-like  translucent  mass  which  is  quite  easily  dis- 
tinguishable from  redissolved  albumen  coagulated  by  heat. 
These  results  led  to  the  belief  that  we  had  a  means  of  diagnosing 
abdominal  fluids,  and  it  was  said  that  if  the  coagulated  albumen 


OVARIAN   FLUIDS  93 

from  them  dissolved  in  acetic  acid  they  were  ovarian ;  and  if  it 
did  not  redissolve,  it  was  said  to  be  ascitic ;  and  that  was  fre- 
quently right.  Sometimes,  however,  part  would  redissolve  and 
part  would  not ;  and  then  the  supposition  was  that  it  was  a 
mixed  fluid,  some  ovarian  and  some  peritoneal ;  that  an  ovarian 
cyst  had  burst  and  some  of  the  fluid  was  in  the  peritoneal 
cavity,  making  a  combined  fluid  which  contained  some  true 
albumen  and  some  paralbumen  ;  and  this  inference  was  really 
often  true,  though  open  to  occasional  exception. 

There  are  sometimes  traces  of  sugar ;  and  fibrinogen,  when 
a  constituent,  may  be  demonstrated  by  applying  A.  Schmidt's 
test,  which  is  the  addition  of  a  few  drops  of  blood  to  the  fluid, 
when  a  distinct  clot  will  form  in  from  twenty-five  to  ninety 
minutes,  involving  the  blood  corpuscles  which  had  been  added. 
The  clot  is  generally  so  firm  that  it  can  be  raised  unbroken,  and 
if  squeezed  in  the  hand  a  quantity  of  fluid  issues  out,  leaving  a 
loose  bundle  of  fibrillated  substance.  Klob  divided  the  contents 
of  an  ovarian  cyst  into  two  portions.  Into  the  one  he  poured 
a  few  drops  of  blood,  and  at  the  end  of  three  hours  the  whole 
was  converted  into  a  mass  as  solid  as  jelly,  while  the  other 
portion  without  blood  showed  no  signs  of  coagulation,  even 
after  long  standing.  Fibrinogen,  however,  is  also  found,  ac- 
cording to  Schmidt  and  Virchow,  in  other  serous  secretions  and 
in  ascitic  fluid.  The  presence  of  fibrine  was  always  regarded 
as  a  proof  of  an  abdominal  fluid  having  been  effused  from  a 
serous  membrane,  not  from  the  secreting  membrane  of  an 
ovarian  cyst.  And  if  fluid  contained  both  fibrine  and  paral- 
bumen, the  supposition  was  that  an  ovarian  cyst  had  burst  and 
there  was  a  mixture  of  two  fluids.  If  no  fibrine  could  be  de- 
tected in  ovarian  fluid  taken  from  the  peritoneal  cavity,  then 
it  was  supposed  that,  instead  of  preserving  their  own  chemical 
characters  after  admixture,  the  fibrinogenous  elements  of  the 
serous  fluid  were  acted  upon  by  the  paralbumen  in  such  a  way 
as  to  interfere  with  the  characteristic  coagulation. 

Dr.  Schetelig,  of  Hamburg,  who  has  diligently  studied  this 
subject,  informs  me  that,  in  a  case  he  watched  at  Breslau,  the 
presence  of  fibrine  in  the  fluid  at  the  first  tapping  showed  that 
it  was  purely  ascitic — while,  on  the  tapping  being  repeated, 
coagulation  did  not  take  place,  and  paralbumen  was  detected. 
This  was  accounted  for  by  rupture  of  an  ovarian  cyst  into  the 


94  CHEMICAL  CONSTITUENTS   OF 

peritoneal  cavity,  a  supposition  which  was  subsequently  proved 
to  be  correct  at  the  time  of  ovariotomy. 

Nor  does  the  presence  of  fibrine  prove  that  the  fluid  is  not 
ovarian,  for  in  a  dermoid  tumour  containing  bones  and  hair, 
which  I  removed  in  June  1869,  Dr.  Schetelig  made  out  three, 
distinct  kinds  of  fluids  in  a  number  of  isolated  cysts.  In 
some  there  was  an  emulsion  of  fat  and  cholesterine ;  in  others 
the  albuminoid  liquid  so  common  in  ovarian  dropsy;  and 
thirdly,  in  different  parts  of  the  large  tumour,  '  certain  small 
isolated  bags  full  of  a  limpid  thin  serum,  which,  being  exposed 
to  the  atmosphere,  soon  coagulated  like  any  other  serous  fluid 
overcharged  with  fibrine.' 

The  more  consistent  colloid  substances  are  occasionally  dis- 
tributed in  ovarian  cysts  in  a  very  peculiar  manner.  They 
form  conical  columns  with  their  broad  bases  directed  outwards. 
Between  these  almost  isolated  columns,  a  whitish  or  yellowish 
white  matter,  consisting  of  epithelial  cells  in  a  state  of  dege- 
neration, is  placed  without  any  definite  arrangement.  Such 
cysts  have  probably  been  formed  by  the  confluence  of  several 
smaller  cysts  of  which  nothing  remains  but  the  epithelial 
investment  undergoing  fatty  decay,  and  so  tracing  out  the 
former  lines  of  separation. 

The  chemical  examination  of  colloid  substances  and  other 
fluids  from  multilocular  cysts  has  given  results  of  the  most 
contradictory  kind,  as  is  seen  by  Dr.  Menu's  assertion,  that  he 
has  never  found  a  trace  of  mucin  in  ropy  ovarian  fluids ;  but 
this  may  be  explained  by  the  supposition  that  operators  have 
not  all  had  the  same  opportunity  of  collecting  a  great  variety 
of  specimens,  and  have  not  dealt  with  the  matter  in  the  same 
stages  of  transformation. 

While  it  is  certain,  therefore,  that  in  cases  of  doubtful 
diagnosis  complete  reliance  cannot  be  placed  on  the  chemical 
characters  of  fluids  removed  from  the  abdomen,  and  that  the 
rule  of  paralbumen  being  the  characteristic  of  ovarian  fluids,  and 
fibrine  of  serous  fluids,  and  the  conjoint  presence  of  paralbumen 
and  fibrine  pointing  to  a  mixture  of  the  two  fluids,  is  open  to 
many  exceptions,  it  is  still  true  that  the  rule  is  sufficiently  often 
correct  to  become  an  aid  of  much  value  in  arriving  at  a  diag- 
nosis, and  to  encourage  us  to  attain  more  accurate  knowledge 
by  more  extensive  observation  and  more  complete  research. 


OVAKIAN   FLUIDS  95 

The  most  recent  publication  on  this  subject  is  the  '  Etude 
sur  les  Liquides  extraits  des  kystes  ovariques,'  by  Dr.  C. 
Mehu,  Pharmacien  de  l'Hopital  de  la  Charite,  which  appeared 
this  year  in  the  '  Archives  Grenerales  de  Medecine  '  for  the 
month  of  September.  In  it  he  states  that  all  his  investiga- 
tions, microscopic  and  chemical,  were  made  upon  fluids  drawn 
from  the  living  patient — never  from  cysts  after  ovariotomy  or 
from  the  dead  body : — 

That,  while  he  found  the  proportion  of  organic  matter  to 
vary  from  2*50  grammes  to  more  than  140  grammes  in  the 
kilogramme  of  filtered,  and  200  grammes  or  more  in  the  un- 
filtered  ovarian  fluids,  the  weight  of  mineral  salts  obtained 
from  the  same  quantity  was  nearly  uniform,  from  7  to  9 
grammes,  generally  between  8  grammes  and  8*50  grammes : — 

That  he  could  almost  always  trace  the  appearance  of  liquid 
oil  to  its  use  on  the  trocar : — 

That  the  fatty  matters  found  on  the  surface  of  the  turbid 
fluids,  after  being  heated  for  a  certain  time  and  then  cooling 
at  rest,  are  the  products  of  the  disintegration  of  the  granular 
aggregations  and  cells  containing  translucent  granules  often 
floating  in  the  recent  fluids  : — 

That  the  aggregations  of  granular  matter  are  simply  ad- 
herent without  envelopes : — 

That  he  considers  the  large  transparent  cells  with  granular 
contents  to  be  leucocytes  considerably  enlarged,  and  not  in  any 
way  characteristic  of  ovarian  fluids ;  as  he  had  seen  them  as 
often  in  the  fluids  of  ascites,  hydrocele,  old  serous  cysts  and 
hematoceles,  especially  when  the  collection  was  of  long  date  : — 

That  he  discovered  cholesterine  only  nine  times  in  1 1 5  ovarian 
fluids  taken  from  61  patients,  never  in  larger  quantity  than  30 
centigrammes  in  the  kilogramme ;  that  even  the  small  amount 
of  10  centigrammes,  which  was  the  most  frequent,  gave  the 
glittering  appearance  in  sunlight ;  and  that  it  was  very  rarely 
seen  in  ascitic  fluid — only  twice  in  300  cases,  one  of  which 
had  an  ovarian  tumour,  and  the  other  partial  peritonitis  with 
Bright's  disease : — 

That  the  absence  of  spontaneously  coagulable  fibrine  is  the 
only  characteristic  which  he  has  found  distinguishing  ovarian 
fluids  from  those  of  ascites,  since  in  pure  ascitic  fluids  after 
twenty-four  hours'  rest  there  is  almost  always  a  deposit  of  some 


96  DR.    MEHU'S   CONCLUSIONS 

centigrammes  per  kilogramme  of  fibrine  taking  the  form  of 
elastic  filaments  after  washing,  especially  when  the  effusion 
has  been  caused  by  the  irritation  of  a  tumour ;  while  ovarian 
fluids  never  give  a  deposit  of  this  kind  spontaneously,  and 
acetic  acid  only  causes  the  separation  of  a  small  quantity  of 
soft  matter  not  in  any  way  elastic  : — 

But  that,  in  connection  with  this  observation,  it  must  be 
remembered  that  when  containing  a  large  quantity  of  leucocytes 
ascitic  fluid  does  not  yield  a  deposit  of  fibrine,  and  that  it  is 
necessary  to  make  allowance  for  the  admixture  of  blood  in  the 
ovarian  fluids  : — 

That,  as  ascitic  fluids  never  contain  more  solid  matter  than 
the  serum  of  the  blood,  any  filtered  serous  fluid  from  the  ab- 
dominal cavity  of  which  the  dry  residue  weighs  more  than  70 
grammes  per  kilogramme  may  be  pronounced  ovarian,  and  that 
with  a  proportion  of  80  grammes  or  more  there  can  be  no 
longer  any  doubt  :— 

That  this  point  of  diagnosis  only  applies  to  the  minority  of 
cases,  as  the  greater  number  of  ovarian  fluids  leave  a  deposit  of 
less  than  70  grammes  : — 

That  the  only  cases  of  cure  after  tapping  are  those  in  which 
the  fluid  comes  from  a  simple  cyst,  is  clear,  free  from  albumen, 
and  yields  a  residue  of  not  more  than  18  grammes  to  the  kilo- 
gramme : — 

That  the  composition  of  the  fluids  varies  very  much  in  twin 
tumours,  in  the  different  parts  of  a  multilocular  tumour,  and  at 
the  earlier  or  later  stages  of  the  same  tapping  : — 

That  the  viscidity  of  the  ropy  ovarian  fluids  is  due  to  par- 
albumen,  which  has  never  yet  been  produced  separately  in  a 
pure  state  ;  and  that  he  has  never  found  a  trace  of  mucin  in 
them. 

It  is  to  be  regretted  that  the  service  afforded  to  our  diag- 
nosis of  abdominal  fluids  by  assisted  sight  is  not  much  better 
than  uncertain.  Microscopical  science  in  its  application  to 
medicine  requires  the  skill,  aptitude,  and  discrimination  of  an 
expert.  Observations  made  without  wide  experience,  the  most 
scrupulous  precautions,  and  an  absolute  freedom  from  specula- 
tive bias  are  absolutely  misleading.  In  ordinary  practice  the 
necessary  qualifications  and  conditions  are  rarely  at  command. 
Such  work  as  has  been  clone  hitherto  leaves  us  in  this  position, 


EVIDENCE    OF    MALIGNANT    DISEASE  97 

that  we  can  hope  for  no  positive  guidance  in  forming  our  judg- 
ment, and  must  be  satisfied  if  we  can  sometimes  get  a  slight 
confirmation  of  opinions  by  the  ocular  interpretations  of  objects 
under  magnifying  power. 

Long  ago  Dr.  Hughes  Bennett,  of  Edinburgh,  took  this  matter 
of  the  investigation  of  ovarian  fluids  in  hand,  and  he  was  followed 
by  Mr.  Nunn.  Both  observed  the  same  granular  cells  and  gra- 
nular matter  in  many  of  their  examinations,  and  Dr.  Drysdale 
has  done  so  too.  Dr.  Bennett  and  Dr.  Drysdale  are  disposed  to 
regard  them  as  diagnostic,  but  Mr.  Nunn  accepts  them  as  of 
only  secondary  importance  as  a  point  of  evidence.  Dr.  Peaslee 
remarks  upon  their  frequent  absence  from  fluids  taken  from 
cysts  removed  from  the  ovary,  and  thinks  the  utmost  that  can  be 
said  is  that  they  give  a  presumption  of  ovarian  fluid  when  seen. 
The  later  work  of  Foulis  and  Thornton  does  not  add  any 
greater  certainty  to  this  question ;  but  they  have  gone  a  step 
further,  and  pointed  out  that  in  cases  of  ovarian  or  peritoneal 
cancer  or  sarcoma  there  are  to  be  found  in  the  abstracted  fluid 
evidences  in  the  shape  of  what  they  call  '  characteristic  groups 
of  cells.'  These  they  describe  as  large  pear-shaped  round  or  oval 
cells  containing  a  granular  material,  with  one  or  several  large 
clear  nuclei  with  nucleoli  and  a  number  of  transparent  globules 
or  vacuoles.  The  cells  composing  the  groups  are  many  of  them 
very  large,  but  the  great  variety  in  size  and  shape  is  the 
marked  feature  of  the  group. 

The  discovery  of  these  objects  ought  no  doubt  to  put  us  on 
our  guard  when  we  have  to  deal  with  tumours  doubtfully 
malignant.  If  seen,  one  may  be  pretty  certain  that  the 
tumour  is  in  some  way  malignant ;  or,  if  they  be  found  in 
fluid  removed  from  the  peritoneal  cavity,  probably  a  sort  of  in- 
fecting process  has  been  going  on  there,  from  the  rupture  of  an 
ovarian  cyst  of  a  malignant  character.  These  cells  may  have 
planted  themselves  and  multiplied,  or  they  may  have  given  a 
taint  to  the  cells  of  the  part  and  influenced  them  to  a  malig- 
nant form  of  reproduction.  The  truth,  however,  really  is  that 
malignant  disease  is  a  condition  of  degradation.  Nutrition  is 
imperfect  and  development  is  misdirected.  It  has  no  specific 
form  of  cell,  but  such  cells  as  are  produced  in  its  growth  are 
deformed,  distorted,  and  early  necrosed  ;  and  the  microscopic 
objects  we   find  in  general  in  the  suspicious  ovarian  fluids  are 

u 


98 


ENCYSTED    DROPSY 


nothing  more  than  groups   of  cells,   some   proliferating  with 
rachitic  profusion  and  monstrous,  others  either  dying  or  dead ; 


all  being  evidence  of  abnormally  rapid  growth,  retrograde 
change,  and  the  early  death  of  successive  generations  of  de- 
generate cells,  the  essential  characteristics  of  malignant  disease. 

DIAGNOSIS    OF    ENCYSTED    DROPSY,    AND    CHANGES    PRODUCED    BY 
CHRONIC    INFLAMMATION   AND    CANCER    OF    THE   PERITONEUM. 


The  fluid  poured  out  as  the  result  of  inflammation  of  the 
peritoneum,  instead  of  lying  free  in  the  cavity,  is  sometimes 
confined  in  pouches  formed  by  adhesions  among  the  viscera, 
or  by  false  membrane  deposited  during  the  disease,  or  by 
attachments  of  the  omentum  or  mesentery. 

In  his  classical  work  'On  Diseases  of  Women,'  Dr.  West 
says :  *  One  instance  of  this  latter  occurrence  has  come  under 
my  own  observation,  in  which  between  four  and  five  quarts 
of  a  dark  fluid  were  found  collected  between  the  folds  of  the 
omentum,  and  during  the  patient's  lifetime  frequent  discharges 
of  a  similar  fluid  had  taken  place  from  the  umbilicus.  The 
dropsy  had  during  the  life  of  the  patient  been  supposed  to  be 
ovarian;  but  though  malignant  disease  of  both  ovaries  was 
discovered,  yet  neither  of  them  contained  fluid  at   all  similar 


CASE    OF    CHRONIC    PERITONITIS  99 

in  character  to  that  which  was  found  in  the  omentum  ;  nor, 
indeed,  could  either  be  detected  till  after  the  fluid  in  the 
omental  cyst  had  been  let  out.  I  am  aware  of  no  means  by 
which  such  cases  are  to  be  discriminated  from  ovarian  dropsy  ; 
as  far  as  I  know,  their  nature  has  scarcely  ever  been  suspected 
during  the  lifetime  of  the  patient.' 

The  fluctuation,  even  if  distinct,  is  always  limited  in  extent, 
and  confined  to  the  same  spots.  The  intestines  are  found 
behind  or  beside  the  tumour,  and  do  not  as  in  ascites  rise  up 
to  the  front  of  the  abdomen,  or  vary  with  the  position  of  the 
patient.  The  appearance  of  the  belly  is  flatter  than  in  cases 
of  tense  ovarian  cysts,  the  distension  is  slower,  the  respira- 
tion is  less  impeded,  and  oedema  of  the  extremities  is  seldom 
seen. 

Sometimes,  too,  the  small  intestine  and  omentum  may  be 
matted  together,  and  the  way  in  which  one  may  be  misled 
under  such  circumstances  is  seen  by  the  following  notes  from 
my  case-book. 

February,  1870. — A  lady,  aged  44,  married  for  four- 
teen years,  was  sent  to  me  by  Dr.  Lowe,  of  Lynn.  She  was 
cachectic,  pale,  and  considerably  emaciated,  with  very  distinct 
fluctuation  of  the  abdomen  in  all  directions ;  the  os  uteri  open, 
and  the  cervix  large.  By  the  vagina,  what  was  supposed  to  be 
a  cyst  could  be  felt  behind  and  above  the  uterus.  The  men- 
struation was  usually  regular,  but  she  had  lately  been  some- 
what over  the  time,  and  had  had  some  flooding.  Four  years 
ago  had  an  early  abortion,  lost  much  blood,  and  was  left  very 
weak.  Within  the  last  two  years  there  had  been  some  increase 
of  size,  but  not  rapid  until  the  last  nine  months,  accompanied 
by  occasional  acute  attacks  of  pain  on  the  right  side,  the  last 
a  year  ago.  Diagnosis ;  ovarian  cyst,  chiefly  one  large  cyst. 
Tapping  was  advised  and  done  immediately.  Seventeen  pints 
of  fluid  were  removed,  a  good  deal  also  being  left  behind.  On 
March  17  she  was  filling  again,  having  had  a  catamenial  dis- 
charge in  February  after  the  operation.  The  urine  was  free 
after  the  tapping,  but  was  now  again  becoming  scanty  and 
thick.  Fluid  could  be  felt  in  the  peritoneal  cavity;  the  uterus 
was  free,  but  the  cyst  could  not  now  be  found  behind  it.  The 
operation  for  removal  of  the  tumour  was  done  on  March  31. 
An  incision  of  four  inches  was  made  between  the  umbilicus  and 

H   2 


100  TUBERCULAR    PERITONITIS 

symphysis  pubis.  The  peritoneum  was  opened  by  a  puncture, 
and  much  clear  fluid  evacuated.  On  enlarging  the  opening  in 
the  peritoneum  enough  to  admit  two  fingers  and  see  within, 
the  whole  of  the  fluid  was  found  to  be  in  the  cavity.  The 
uterus  was  roughened  on  its  peritoneal  surface,  and  both 
ovaries  felt  large,  that  on  the  left  side  as  big  as  a  walnut. 
Above  and  to  the  left  was  a  mass  feeling  very  like  a  multilo- 
cular  ovarian  cyst,  evidently  formed  by  adhering  coils  of  in- 
testine, thickened  peritoneum,  and  omentum.  There  was 
scarcely  any  bleeding,  and  the  wound  was  closed  with  sutures. 
She  had  no  bad  symptoms  after  the  operation ;  the  wound 
healed  well,  and  she  went  home  on  April  16.  In  this  case  the 
uterine  examination  and  the  moving  mass  above  the  umbilicus 
deceived  me ;  the  mass  of  intestine  and  omentum  felt  so  very 
much  like  an  ovarian  cyst.  In  subsequent  eases  percussion  has 
removed  doubt. 

Two  very  similar  cases  are  recorded  in  the  American  jour- 
nals ;  one  in  which  Dr.  McDowell,  after  considering  the  diag- 
nosis as  eertain,  opened  the  abdomen  and  found  nothing  but  a 
mass  of  intestines  conglomerated  by  adhesions ;  the  other  in 
whose  abdomen  the  ovaries  were  discovered  by  Dr.  Henry 
Smith  to  be  sound,  and  the  swelling  due  to  thickened  and 
indurated  omentum. 

But  these  localized  collections  of  fluid  in  the  peritoneum 
may  be  associated  with  cancer  and  tubercle  of  the  membrane, 
and  give  rise  to  difficulties  in  the  diagnosis,  as  in  the  case  of 
an  unmarried  lady,  aged  twenty-two,  whom  I  saw  in  consulta- 
tion with  Mr.  Seymour  Haden  in  1862.  The  abdomen  was  as 
large  as  that  of  a  woman  near  the  full  period  of  pregnancy,  and 
was  distended  uniformly  by  fluid,  which  gravitated  so  decidedly 
to  the  lowest  point  with  all  changes  of  position,  that  it  was 
evidently  free  in  the  peritoneal  cavity  ;  and  looking  to  the  ap- 
pearance of  the  patient,  and  to  the  fact  that  she  had  occasional 
pain,  I  had  little  doubt  as  to  the  disease  being  a  sub-acute  form 
of  tubercular  peritonitis. 

Mr.  Haden,  who  six  weeks  before  had  tapped  the  patient, 
concurred  in  that  opinion,  and  a  tonic  treatment  with  diuretics 
was  commenced.  For  a  time  she  improved,  but  during  the 
autumn  all  the  symptoms  were  aggravated,  and  I  met  Mr. 
Haden  again  on  November  3.     A  remarkable  change  was  then 


CASE    OF    TUBERCLE    AND    ASCITES  101 

found  to  have  taken  place.  The  abdomen  was  much  more  pro- 
minent or  arched  than  before ;  it  was  dull  anteriorly  in  all  posi- 
tions of  the  body,  and  clear  in  both  flanks  as  she  lay  on  her 
back.  Moreover,  on  taking  a  deep  inspiration,  a  cyst  appeared 
to  move  downwards  from  the  epigastrium  beneath  the  parietes. 
Fluctuation  was  evident  in  all  directions.  This  led  me  to 
doubt  the  accuracy  of  my  first  opinion,  and  it  was  arranged 
that  she  should  be  again  tapped,  partly  to  afford  relief,  and 
.  partly  to  clear  up  the  diagnosis.  She  was  tapped  by  Mr. 
Haden  on  November  12,  and  eighteen  pints  of  clear  amber- 
coloured  fluid  were  removed,  which  deposited  a  cloud  of  floc- 
culent  mucoid  substance,  very  much  resembling  that  so  often 
seen  in  ovarian  cysts. 

On  November  19  Mr.  Haden  and  I  examined  her  again  most 
carefully,  with  the  express  purpose  of  ascertaining  whether  we 
were  dealing  with  tubercular  peritonitis  or  with  a  thin  non- 
adherent unilocular  ovarian  cyst.  We  both  felt  it  impossible 
to  arrive  at  a  positive  decision ;  but  while  Mr.  Haden  leaned  to 
the  belief  in  peritonitis,  my  own  impression  was  rather  the 
other  way.  In  this  state  of  uncertainty,  and  feeling  that  re- 
peated tapping  must  be  useless,  it  was  arranged  that  a  small 
incision  should  be  made ;  and  if  a  cyst  was  found  it  should  be 
removed,  whereas  if  there  were  no  cyst  the  incision  would 
serve  instead  of  tapping.  Accordingly  on  December  24,  1862, 
Mr.  Clover  administered  chloroform,  and,  assisted  by  Mr. 
Haden  and  Dr.  Savage,  I  cautiously  made  a  small  incision  below 
the  umbilicus,  and  opened  the  peritoneum.  No  cyst  appeared. 
A  large  quantity  of  opalescent  fluid  escaped,  and  then  the 
whole  of  the  peritoneum  was  seen  to  be  studded  with  myriads 
of  tubercles.  Some  coils  of  small  intestine  were  floating,  but 
the  great  mass  was  bound  down  with  the  colon  and  omentum, 
all  nodulated  by  tubercle,  towards  the  back  and  upper  part  of 
the  abdomen.  The  uterus  and  ovaries  were  felt  to  be  of  the 
normal  size,  but  their  peritoneal  coat  was  very  rough.  All  the 
fluid  was  carefully  pumped  out  by  an  india-rubber  syringe,  the 
wound  was  closed  by  sutures,  and  the  patient  treated  precisely 
as  after  ovariotomy.  She  went  through  rather  a  sharp  attack 
of  peritonitis,  but  after  two  or  three  days  suffered  hardly  more 
than  after  tapping.  She  passed  large  quantities  of  urine,  and 
it  seemed  as  if  the  use  of  the  catheter  excited  this  diuresis— 


102  CANCEROUS   EFFUSION   INTO    PERITONEUM 

so  much  so  that  Mr.  Haden  had  it  continued  long  after  the 
wound  was  healed. 

But  the  most  remarkable  part  of  the  case  remains  to  be 
told.  The  patient  got  well,  married,  and  has  been  well  ever 
since  she  recovered  from  the  operation.  Whether  the  perito- 
nitis set  up  led  to  fresh  adhesions  or  not,  certain  it  is  that  no 
more  fluid  was  secreted,  and  the  patient  regained  health  and 
strength.  The  case  would  serve  as  a  striking  appendix  to 
Martin's  curious  paper  '  On  the  Operative  Treatment  of  Peri- 
tonitis.' 

In  a  note  which  I  received  from  Mr.  Haden,  dated  Novem- 
ber 1,  1864,  he  says,  'By  a  mere  chance  I  happened  to  see 
her  yesterday.  I  met  her  in  the  street.  She  was  perfectly 
well.'  Mr.  Haden  wrote  to  me  again  in  April  1872,  saying 
that  this  lady  '  married  in  1866.  She  has  no  children,  but  is 
stout,  hearty,  and  well.'     I  hear  that  she  is  well  in  1881. 

The  tumour  from  cancer  of  the  peritoneum  may  become  so 
large  as  to  occupy  a  very  great  extent  of  the  abdomen,  but  it 
is  much  more  solid  to  the  touch  than  the  enlargement  due  to 
general  tubercular  disease  of  the  same  part.  It  is  also  some- 
times accompanied,  as  in  a  case  mentioned  by  Dr.  Ballard,  by 
an  effusion  of  gelatinous  matter  into  the  sac,  indicated  during 
life  by  general  and  extreme  filling  up  of  the  abdomen,  with 
great  elevation  of  the  diaphragm  as  in  ascites,  dulness  on  per- 
cussion everywhere  but  at  the  epigastrium  and  along  the 
margin  of  the  ribs  on  the  right  side,  and  the  most  perfect 
fluctuation  in  every  part.  In  fact,  the  symptoms  produced 
by  this  condition  of  the  peritoneum  have  been  sometimes 
so  closely  like  those  met  with  in  many  cases  of  ovarian  cysts 
as  to  deceive  men  of  very  great  experience ;  and  I  have 
repeatedly  been  sent  for  under  such  circumstances  expressly 
to  discuss  the  question  of  ovariotomy,  when  the  patient 
was  not  very  far  distant  from  the  end  of  her  career.  Even 
among  my  own  cases  the  coexistence  of  cancer  has  been 
so  masked  by  the  symptoms  of  ovarian  disease  that  one  has 
been  led  on  by  the  hope  of  giving  operative  relief. 

The  housekeeper  of  a  patient  of  Mr.  Jones  of  Epsom, 
aged  54,  very  corpulent,  in  October  1868  had  a  tumour  in 
the  left  side  about  the  size  of  a  cricket  ball,  which  had  been 
previously  recognized  as  ovarian  by  Drs.  Priestley  and  Farre. 


dANCEROUS   DISEASE   OF   PERITONEUM  103 

Three  years  before,  there  had  been  some  ulceration  of  the  neck 
of  the  uterus,  and  a  vascular  growth  at  the  orifice  of  the 
urethra.  By  the  month  of  December  1868  I  found  the  whole 
abdomen  filled  by  an  elastic  soft  tumour,  indistinctly  fluctuat- 
ing ;  the  pulse  rapid  and  feeble,  bronchial  murmur  in  the 
upper  part  of  both  lungs,  pain  down  the  left  thigh,  and  within 
the  last  ten  days  falling  off  in  the  general  health.  I  advised 
tonics  and  tapping,  as  her  state  was  not  then  favourable  for  the 
operation  of  ovariotomy.  She  was  accordingly  tapped  early  in 
January  1869,  by  Mr.  Jones,  below  the  umbilicus,  with  the 
removal  of  eleven  pints  of  bloody  serum.  On  February  2,  I 
found  her  in  a  much  better  state  of  health,  but  the  tumour 
felt  rather  elastic  than  fluctuant ;  and  though  the  cervix 
uteri  was  mobile,  and  there  was  no  vascular  murmur,  doubts 
as  to  the  uterine  nature  of  the  tumour  arose  in  my  mind,  and  I 
decided  to  begin  the  operation  by  an  exploratory  incision. 

On  Feb.  18,  this  was  accordingly  done.  The  peritoneum 
exposed  was  so  thick  that  I  doubted  whether  it  was  the  cyst 
or  not,  and  so  tapped  rather  than  make  any  separation  of  it. 
Some  pints  of  red  serous  fluid  escaped,  and  more  still  when  the 
trocar  was  withdrawn.  On  enlarging  the  opening  some  small 
intestines  appeared  floating  in  the  remaining  fluid.  It  was 
then  seen  that  a  multilocular  cyst  had  given  way  behind,  and 
that  its  sac  formed  one  general  cavity  with  the  peritoneum. 
Below  a  large  secondary  cyst  was  prominent.  This  I  tapped 
and  emptied,  and  then  found  the  whole  of  the  outer  coat  of  the 
large  cyst  so  intimately  adherent  not  only  to  the  abdominal 
wall,  but  also  to  the  uterus  and  sides  of  the  pelvis,  that  I 
determined  not  to  attempt  any  separation,  especially  as  some 
hardish  white  nodules  which  were  irregularly  scattered  about 
the  cyst  walls  were  very  suspicious  in  appearance,  and  strongly 
suggestive  of  carcinoma. 

Very  little  blood  was  lost,  and  the  wound  was  closed  with 
sutures.  The  operation  confirmed  the  previous  suspicion  which 
had  arisen  as  to  the  rupture  of  a  cyst  before  the  tapping,  and 
the  diagnosis  of  malignant  disease  which  the  cachectic  looks 
and  general  symptoms  had  suggested.  She  died  about  sixty 
hours  after  the  operation. 

Report  of  examination  thirty-eight  hours  after  death  by 
Dr.  Orenser,  of  Dresden. — 'Dressing  had  never  been  removed. 


104  MALIGNANT    DISEASE    WITH 

and  was  nearly  dry.  The  wound  had  united  entirely  outside 
and  inside,  and  nearly  without  any  discharge.  The  peritoneum, 
thickened,  had  entirely  lost  the  character  of  a  serous  membrane 
— represented  a  thick,  tough,  ash-coloured  membrane  extend- 
ing all  over  the  abdominal  cavity  and  its  contents.  It  con- 
tained about  two  pints  of  reddish  fluid  without  clots.  The 
intestines  were  much  distended,  slightly  adherent  to  the 
abdominal  wound,  but  free  in  all  other  parts. 

Cancer  (fungus  medullaris)  of  the  mesocolon  transversum, 
10-12  inches  in  length  and  one  inch  in  breadth,  extending  to 
the  edge  of  the  spleen,  which  is  not  involved.  The  cancer  is 
very  soft,  and  contains  a  great  quantity  of  detritus. 

Multilocular  cyst  of  the  right  ovary,  the  size  of  a  foetal 
skull.  One  cyst  showed  the  trace  of  tapping  during  the 
operation.  The  cysts  do  not  contain  much  fluid,  but  mostly 
cancerous  matter,  not  quite  so  soft  as  the  cancer  of  the  meso- 
colon. 

Strong  adhesive  bands  round  the  uterus  and  the  ovaries, 
which  entirely  surround  and  hide  the  uterus  and  the  left 
ovary,  which  could  not  be  seen  before  separating  the  bands. 
Uterus  small,  healthy,  except  one  small  point,  the  size  of  a  pea, 
on  the  fundus  which  looks  white  and  cancerous.  Cyst  of  the  left 
ovary  the  size  of  a  walnut ;  no  cancer.' 

Another  similiar  case  was  that  of  a  widow,  aged  51,  who  on 
her  admission  to  the  Samaritan  Hospital  in  July  1868  was  in 
a  pallid,  ansemic  state,  much  emaciated,  with  her  feet  cold  and 
cedematous,  and  the  breasts  wasted.  She  had  a  hard,  movable 
nodule  under  the  right  false  ribs,  and  a  tumour  in  the  abdomen 
visibly  movable,  without  any  evidence  of  adhesions.  The 
parietes  of  the  abdomen  were  thin,  marked  with  numerous  linege 
albicantes,  but  there  were  no  dilated  veins.  A  wave  of  fluc- 
tuation was  felt  over  the  surface  of  the  tumour,  and  the  sounds 
on  percussion  were  clear  two  inches  above  the  umbilicus,  dull 
in  the  lumbar  region.  The  cervix  of  the  uterus  was  far  back, 
the  os  open,  and  the  cavity  two  and  a  half  inches  in  length. 
The  tumour  could  be  felt  in  front  of  the  uterus,  and  through 
the  rectum.  The  appetite  was  bad,  with  pain  after  meals  and 
relaxed  state  of  bowels.  She  slept  badly,  lying  best  on  the  left 
side  and  back,  had  great  depression  of  spirits,  and,  though  the 
sounds  of  the  heart  were  normal,  the  pulse  was  96,  very  weak 


PILIFEKOUS   CYST   OF   OVARY  105 

and  thready.  She  came  of  a  healthy  family,  had  lived  in  the 
country  comfortably,  and  notwithstanding  her  delicacy  had 
never  been  seriously  ill. 

The  tumour  began  to  form  about  twelve  years  before,  but 
caused  no  inconvenience  for  six  years.  It  then  grew  rapidly, 
filling  the  abdomen,  without  much  pain,  but  giving  rise  to 
sickness,  loss  of  appetite,  irregularity  of  the  bowels,  and  cramps 
in  the  left  leg.  The  size  had  so  much  augmented  of  late  that 
she  had  great  dyspnoea  and  was  unable  to  walk.  I  had  seen  her 
in  1866,  and  then  diagnosed  '  Uterine  tumour,  probably  malig- 
nant.' At  the  date  of  admission,  in  1868,  I  wrote,  '  Abdominal 
tumour,  surrounded  by  ascitic  fluid — if  uterine,  an  out-growth, 
as  the  tumour  can  be  moved  without  moving  the  cervix.'  She 
was  twice  tapped,  about  twelve  pints  of  clear  and  slightly  coagul- 
able  fluid  being  drawn  off  from  the  peritoneum  each  time. 

On  August  3,  a  tentative  incision  was  made.  A  white 
glistening  tumour  was  exposed  on  dividing  the  peritoneum.  A 
few  pints  of  clear  fluid  escaped,  and  I  then  felt  the  movable 
nodule  under  the  right  false  ribs  to  be  apparently  a  lump  of 
cancer  in  the  abdominal  wall.  The  uterus  and  ovaries  seemed 
to  be  fused  together,  the  intestines  adhering  behind ;  there 
were  also  some  slight  but  vascular  parietal  adhesions.  I  did 
nothing  more,  and  closed  the  wound.  There  was  scarcely  any 
haemorrhage.  She  died  about  ten  days  after  the  operation. 
The  skin  surface  of  the  incision  had  not  healed ;  there  was  some 
pus  in  the  subcutaneous  cellular  tissue,  but  the  peritoneal  edges 
of  the  wound  were  firmly  united.  There  were  about  three  or 
four  pints  of  serum  in  the  peritoneal  cavity,  and  adhesions  of 
the  omentum  and  transverse  colon  to  the  upper  part  of  the 
tumour.  A  hard,  white  nodule  as  large  as  a  walnut,  in  the 
abdominal  wall  below  the  right  false  rib,  was  found  by  Dr. 
Junker  to  consist  of  fibrillated  connective  tissue,  with  large 
oblong,  nucleated  cells  in  an  advanced  stage  of  fatty  degenera- 
tion. Both  ovaries  were  fused  together,  and  formed  one 
tumour  ;  unless  a  sebaceous  and  piliferous  cyst  on  the  left  side 
was  formed  exclusively  by  the  left  ovary,  and  the  rest  of  the 
tumour  by  the  right.  The  uterus  was  small  and  normal,  but 
closely  connected,  without  anything  like  a  pedicle  on  either 
side,  with  the  ovarian  growths.  The  liver  was  small,  not  hard, 
and  its  peritoneal  coat  adhered  to  the   abdominal  wall  and 


106  TYMPANITES   AND   PHANTOM   TUMOURS 

diaphragm.  The  tumour  was  sent  to  Dr.  Wilson  Fox,  who 
reported  that  '  he  could  find  nothing  but  the  ordinary  cystic 
development.  In  fact,  there  were  very  few  solid  portions,  less 
indeed  than  in  many.  There  was  much  hyperemia  in  many 
parts,  and  in  others  large  tracts  of  fatty  degeneration.  The 
dermoid  formation  was  limited  to  a  very  small  portion  of  the 
tumour,  and  to  one  or  two  cysts.  This  seems  often  to  be  the 
case.  It  is  rather  singular  that  it  should  be  so.  In  this  part 
there  was  much  sebaceous  material.' 

In  all  such  cases  suspicion  of  their  real  nature  should  be 
aroused  if  a  patient  has  either  a  very  thin  and  tense,  or  an 
oedematous  abdominal  wall,  anasarca  of  the  lower  limbs,  general 
emaciation,  a  cachectic  aspect,  free  fluid  in  the  peritoneal  cavity, 
and  especially  so,  if  the  loss  of  flesh  and  amount  of  pain  are 
more  rapid  and  severe  than  an  ovarian  or  other  innocent 
temour  would  account  for. 

TYMPANITES   AND   PHANTOM   TUMOURS. 

One  may  easily  understand  how  tympanitic  distension  of 
the  abdomen,  which  is  not  unfrequently  seen  in  hysterical 
women,  may  give  rise  to  some  awkward  questions ;  but,  ex- 
cept from  personal  observation,  or  the  testimony  of  men  so 
accurate  as  Bright,  Simpson,  or  Boinet,  it  is  difficult  to  be- 
lieve that  any  surgeon  of  reasonable  experience,  or  in  his 
right  senses,  could  be  so  deluded  by  such  a  condition  as 
to  think  that  he  had  before  him  a  case  of  solid  ovarian 
tumour,  and  attempt  the  operation  of  ovariotomy.  Yet 
Simpson  says  that  it  has  happened  no  less  than  six  times,  and 
Bright  published  the  following  case  in  his  work  on  Abdo- 
minal Tumours :  '  Susannah  J.,  eet.  30,  said  to  have  been  ill 
for  two  years,  was  admitted,  under  my  care,  into  Charity  Ward, 
September  29,  1824,  complaining  of  abdominal  pain  and 
some  hysteric  symptoms.  She  had,  in  the  middle  line  of 
the  abdomen,  about  half-way  between  the  umbilicus  and  sym- 
physis pubis,  an  unhealed  scar,  of  about  three  inches  in 
length.  The  deeper  part  of  the  wound  had  united,  and  it  was 
filling  up  by  granulation,  as  was  a  portion  of  the  external 
part,  at  each  end  of  the  scar.  It  was  evidently  an  incised 
wound,  and  the  account  she  gave  was  that  her  abdomen  being 


CASES    OF   HYSTERIC    TYMPANITES 


107 


swollen,  as  it  was  at  the  time  she  had  formerly  been  in  the 
hospital,  a  surgeon  proposed  to  her  the  excision  of  a  tumour 
which  produced  this  swelling,  and  that,  with  two  assistants,  he 
prepared  to  perform  the  operation,  and  made  a  free  incision  into 
the  abdominal  cavity  ;  but  finding  that  there  was  no  tumour, 
brought  the  wound  together,  which  now,  after  the  lapse  of 
several  weeks,  was  as  we  saw  it.  The  wound  healed  completely 
under  common  treatment,  but  her  health  remained  in  a  most 
unsatisfactory  state,  both  from  the  frequent  tendency  to 
diarrhoea  and  from   the  succession   of  pains,  with    occasional 


puffing  up  of  the  abdomen,  of  which  she  was  the  subject,  so 
that  she  remained  in  the  hospital  till  December  28. 

'  During  this  long  confinement  the  tumour  of  the  abdomen 
varied  a  good  deal,  and  was,  on  one  or  two  occasions,  reported 
to  have  subsided  entirely. 

'  I  may  mention  further  that  I  had  seen  this  young  woman 
many  years  before,  when  she  was  in  Gruy's  Hospital  for  a  sup- 
posed abdominal  tumour,  under  Dr.  Marcet,  who,  however,  soon 
discovered  its  hysteric  character,  though,  certainly,  the  abdo- 
men bore  a  very  peculiar  appearance,  strongly  resembling  an 
encysted  tumour ;  but  there  were  connected  with  this  supposed 
tumour  so  many  other  ailments,  embracing  fits  of  hysterics, 


108 


CASES  OF   HYSTERIC   TYMPANITES 


epilepsy,  paralysis,  abdominal  and  lumbar  pains,  so  varied  and 
so  changing,  that  a  little  observation  was  sufficient  to  convince 
any  experienced  person  of  its  real  character.' 

Boinet  relates  also  that  a  miserable  woman  of  weak  intellect, 
tympanitic  and  impressed  with  the  notion  that  she  had  an 
abdominal  tumour,  was  unfortunate  enough  to  meet  with  two 
or  three  surgeons  who,  from  some  unaccountable  motives, 
persuaded  themselves  that  she  had  ovarian  disease,  and  gave 
way  to  her  importunate  demands  for  an  operation.  Their  rash 
gastrotomy  only  showed  the  existence  of  cancer,  and  killed  the 
woman. 


These  hysterical  distensions  of  the  abdomen  present  them- 
selves in  a  variety  of  forms.  Sometimes  the  belly  is  uniformly 
blown  up  to  the  size  of  advanced  pregnancy,  and  is  rounded, 
hard,  and  resistant.  The  hand  makes  no  impression  on  it,  and 
change  of  position  causes  no  alteration  in  shape.  But,  of 
course,  there  is  no  fluctuation — the  resonance  is  universal, 
hysterical  symptoms  are  generally  present,  and,  under  the 
influence  of  chloroform,  the  swelling  entirely  disappears, 
leaving  the  abdomen  flaccid,  and  allowing  the  hand  to  rest 
upon  the  hard  bones  of  the  spine.  In  other  cases  the  dis- 
tensions are  local,  and  it  is  noticed  that  they  occur  more  often 


HYSTERIC   TYMPANITES 


109 


on  the  right  side.  Portions  of  the  abdominal  wall  are  gathered 
up  into  rigid  knots,  which  remain  so  long  unaltered  as  fully  to 
simulate  an  internal  tumour,  especially  as  they  are  sometimes 
situated  over  accumulations  of  hardened  fseces,  and  are  accom- 
panied by  a  good  deal  of  tenderness  of  the  parts.  Careful 
and  patient  palpation,  purgatives,  and  chloroform  will  gener- 
ally lead  to  a  solution  of  the  mystery,  or  may  even  dis- 
close the  existence  of  an  unsuspected  incipient  ovarian  tumour, 
which,  by  its  presence  in  the  pelvis,  had  given  rise  to  the  train 
of  hysterical  symptoms,  and,  among  others,  to  the  superimposed 


swelling,  apparently  the  most   important   matter  calling   for 
treatment. 

The  drawing  on  page  107,  from  a  photograph  by  the  late 
Dr.  Wright,  shows  how  very  accurately  one  of  these  phantom 
tumours,  or  the  condition  which  I  have  now  been  describing  as 
hysteric  tympanites,  may  resemble  a  uterine  or  ovarian  tumour. 
The  lower  part  of  the  abdomen  arches  forward  exactly  as  in 
pregnancy,  or  as  in  an  ovarian  tumour  of  moderate  size  when 
the  abdominal  wall  is  not  lax ;  and  the  wall  is  so  tense,  the 
patient  so  resists  pressure,  or  complains  so  much  of  tenderness  on 
pressure,  and  the  abdominal  muscles  contract  so  spasmodically 
and  irregularly,  that  it  is  by  no  means  difficult  to  fancy  that  a 
tumour,  or  even  the  movements  of  a  foetus,  may  be  felt.  The 
girl,  whose  portrait  is  here  given,  was  in  the  Samaritan  Hos- 


110  HYSTERIC   TYMPANITES 

tal  for  some  time,  and  it  was  difficult  to  convince  her,  her 
friends,  and  even  some  medical  friends  who  saw  her  with  me, 
that  she  had  no  abdominal  tumour.  The  tympanitic  reson- 
ance on  percussion  was,  of  course,  the  leading  element  in  the 
diagnosis ;  but  the  most  conclusive  test  was  the  complete  sub- 
sidence of  the  swelling,  and  the  flattening  of  the  abdomen  when 
the  girl  was  fully  under  the  influence  of  chloroform.  The  pho- 
tograph from  which  the  second  drawing  was  taken  was  made 
while  she  was  completely  narcotised.  The  arched  abdomen  is 
seen  to  have  been  quite  flattened,  and  it  was  easy,  when  the 
abdominal  walls  were  so  flaccid,  to  feel  the  pulsations  of  the 
aorta,  the  vertebral  column,  the  brim  of  the  pelvis,  and  to 
become  perfectly  certain  that  there  was  no  abdominal  nor  pelvic 
cyst  of  any  kind.  Yet  the  instant  the  effect  of  the  chloroform 
began  to  pass  away  the  tumour  always  began  to  reappear.  This 
was  shown  several  times  when  the  experiment  was  tried,  and 
on  one  occasion  Dr.  Wright  took  a  photograph  (p.  109)  when  she 
was  nearly  awake,  and  the  tumour  was  almost  as  prominent  as 
in  her  ordinary  condition,  shown  in  the  first  drawing.  She  was 
an  hysterical  girl,  but  there  was  no  voluntary  or  conscious  im- 
position on  her  part  so  far  as  I  could  ascertain.  She  improved 
under  a  course  of  purgatives  and  steel,  but  I  have  not  seen  her 
since  she  left  the  hospital.  In  one  woman  the  abdominal  wall 
thus  expanded  gave  rise  to  a  suspicion  of  double  ovarian  cyst. 
The  recti  muscles  formed  a  distinct  line  of  demarcation 
between  two  protuberances.  The  supposed  tumour  seemed  to 
be  well  defined,  but  the  belly  resumed  its  natural  shape  under 
chloroform. 

Early  in  1872,  a  woman  was  sent  to  the  Samaritan  Hospital, 
supposed  to  be  suffering  from  a  large  ovarian  tumour.  The 
tympanitic  resonance,  with  the  absence  of  fluctuation,  at  once 
showed  that  there  could  be  no  large  abdominal  tumour,  but  some 
hardness  above  the  pubes  led  to  a  vaginal  examination,  when 
an  early  pregnancy  was  detected.  On  administering  chloroform 
the  distended  abdomen  at  once  flattened  down,  and  the  outline 
of  the  enlarged  uterus  could  be  distinctly  traced.  This  is  the 
only  case  in  which  I  have  seen  tympanites  occur  in  a  pregnant 
woman.  I  have,  however,  several  times  seen  it  accompany 
small  fibroid  tumours  of  the  uterus,  uterine  polypi,  uterine 
displacements,  and  small  ovarian  tumours  which  have  not  risen 


CASES    OF   PERITONEAL    FATTY    TUMOURS  111 

out  of  the  pelvis.  Once  only  have  I  met  with  this  voluminous 
turgidity  in  a  man,  and  with  him  I  had  no  difficulty.  He  was 
one  of  the  Crimean  invalids,  and  came  into  my  hands  at 
Smyrna. 


FIBRO-PLASTIC   AND    FATTY    TUMOURS    OF    PERITONEUM,    OMENTUM, 
AND   SUB-PERITONEAL   CELLULAR   TISSUE. 

The  symptoms  caused  by  the  growth  of  large  fatty  and 
fibro-plastic  tumours  from  various  parts  of  the  peritoneum  or 
mesentery  so  much  resemble  those  of  true  ovarian  disease, 
that  their  real  nature  can  only  be  determined  in  some  cases 
by  an  exploratory  incision  or  tapping.  The  difficulties  and 
dangers  attending  these  obscure  diseases  are  exemplified  in 
the  histories  of  the  cases  which  now  follow. 

A  lobulated  mass  of  fat  weighing  twenty  pounds  was  re- 
moved from  an  unmarried  lady,  forty-three  years  of  age.  She 
had  been  suffering  several  years  from  an  abdominal  tumour,  and 
for  more  than  a  year  had  been  confined  to  her  room.  Various 
opinions  had  been  entertained  as  to  the  nature  of  the  tumour, 
and  on  October  24,  1867,  I  made  an  exploratory  incision,  and 
found  that  the  tumour  was  a  mass  of  fat.  The  opening  was 
closed  to  gain  time  for  consultation  as  to  future  treatment. 
The  wound  united  well.  The  patient  suffered  very  little,  and 
it  was  arranged  that  an  attempt  should  be  made  to  remove  the 
tumour.  This  was  done  on  November  5,  1867,  and  large 
masses  of  fat  were  extracted  after  dividing  a  loose  cellular  cap- 
sule. A  large  lobule  felt  in  the  neighbourhood  of  the  right 
kidney  was  not  disturbed.  Not  more  than  three  or  four  ounces 
of  blood  was  lost.  Four  vessels  were  tied  in  the  tissue  of  the 
capsule.  The  tumour  appeared  to  have  originated  in  the 
mesentery.  Some  of  the  lobules  were  evidently  appendices 
epiploicw  enormously  hypertrophied. 

The  patient  died  fifty-eight  hours  after  the  operation.  On 
post-mortem  examination,  traces  of  recent  peritonitis  were  ob- 
served, but  none  of  bleeding.  The  mass  of  fat  left  on  the 
right  side  involved  the  right  kidney,  pushed  the  ascending 
colon  over  to  the  left,  and  adhered  to  the  under  surface  of  the 
liver.  Many  mesenteric  glands  were  enlarged  and  enveloped 
in  fat.     There  was  not  more  fat  than  usual  in  the  omentum. 


112  FATTY   TUMOURS 

The  weight  of  the  portion  of  fatty  tumour  not  removed  during 
life  was  estimated  at  ten  or  twelve  pounds,  but  it  was  not 
weighed.     The  uterus  and  both  ovaries  were  healthy. 

Mr.  J.  Cooper  Forster,  in  the  '  Pathological  Transactions,' 
vol.  19,  records  another  case  of  fibro-fatty  tumour  of  the  abdo- 
men, weighing  fifty-five  pounds.  Dr.  Moxon  said  the  micro- 
scopic examination  showed  in  all  parts  a  large  proportion  of 
ordinary  fat-cells.  In  the  greater  part  of  the  tumour — the 
part  that  had  the  appearance  of  common  healthy  fat — these, 
with  the  usual  connective  filaments  and  vessels,  made  up  the 
tissue,  which  was  histologically  perfect  fat. 

The  wife  of  a  railway  guard,  aged  twenty- six,   living   at 
Bromley,  Kent,  was  admitted  into  the  Samaritan  Hospital  from 
St.  Bartholomew's  in  December  1869.    She  had  a  child  two 
years  before.     After  her  confinement  she  felt  a  small  lump  in 
the  right  iliae  region.     This  increased  very  slowly  until  the 
May  of  1869,  and  caused  very  frequent  nausea.     After  May 
the  growth  was  rapid ;  and  the  diagnosis  was — Ovarian  tumour, 
closely  connected  with  the  uterus.     On  February  23,  1870,  an 
exploratory  incision  was  made.     On  exposing  the  peritoneum 
some  large  veins  were  seen  on  the  surface  of  a  dark  blue  tumour 
which  was  very  elastic.     Avoiding  the  veins,  a  trocar  was  in- 
troduced, and  three   or   four  pints  of  bloody  serum  escaped. 
Then  I  perceived  that  the  tumour  was  an  extremely  vascular, 
soft,  friable,  granular  mass,  and  satisfied  myself  by  stopping 
the   bleeding,  which   was  rather  free  both  from  arteries  and 
veins.     Two  or  three  were  tied ;  solid  perchloride  of  iron  was 
passed  into  the  cavity,  and  two  pins  were  introduced,  around 
which  silk  was  twisted,  to  close  the  opening.     The  pins  were 
fastened  outside  the  abdominal  cavity,  and  the  wound  closed 
with  sutures.     She  died  March  3,  and,  on  examining  the  body 
eighteen  hours  after  death,  I  found  the  tumour  to  be  firmly 
adherent  to  the  abdominal  wall,  to  the  liver  and  intestines,  and 
to  the  uterus  behind ;  but  both  uterus  and  ovaries  were  free 
from  disease.     In  some  parts  there   were  detached   bodies  like 
large  appendices  epiploicse,  and  from  some  of  the  intestines 
there  were  cyst-like  growths,  which  I  sent  with  the  tumour, 
liver,  spleen,  and  kidneys  to  Dr.  Wilson  Fox,  whose  report 
follows : — 

'  I  have  examined  the  masses  which  you  were  kind  enough 


CASE    OF   FIBROPLASTIC   TUMOUR  113 

to  send  to  me,  microscopically.  They  appear  to  be  of  a  malig- 
nant nature,  but  rather,  perhaps,  occupying  a  doubtful  place 
between  true  cancer  and  fibro-plastic  growth.  As  far  as  I  can 
make  out  their  origin,  it  appears  to  be  either  omental  or  peri- 
toneal. The  growths  on  the  intestine  appear  to  originate  very 
distinctly  in  the  serous  covering.  They  consist  almost  entirely 
of  spindle-shaped,  and  caudate,  and  large  round  nucleated 
cells,  together  with  an  abundant  supply  of  blood-vessels,  which 
are  very  large  and  greatly  distended.  In  many  places  these  have 
ruptured  both  on  a  large  and  on  a  small  scale.  Whether  such 
extravasations  have  been  the  origin  of  the  cysts  is  in  all  cases 
difficult  to  determine.  In  some  places  this  mode  of  origin  is 
pretty  distinct ;  in  others,  the  cysts  appear  to  originate  from 
an  acute  fatty  disintegration  and  softening  of  parts  of  the 
tumours  ;  but  in  others  the  cysts  appear  to  have  originated  as 
spaces  filled  with  a  sort  of  albuminoid,  semi-fluid  material 
analogous  to  those  found  in  enchondromata.  I  could  find  no 
secondary  implication  of  the  other  organs — a  fact  which 
appears  to  militate  against  the  malignant  nature  of  the  original 
mass.  The  liver,  spleen,  and  kidneys,  all  softened  and 
"  cloudy,"  present  merely  the  affection  common  to  these  organs 
in  septic  and  acute  inflammatory  disease.' 

In  Yirchow's  '  Archives  of  Pathological  Anatomy  '  (Bd.  63, 
No.  4)  he  describes  a  retroperitoneal  tumour,  which  I  removed 
from  a  lady  in  Pomerania  in  May  1875,  and  left  with  him  on 
my  return  through  Berlin  for  examination,  as  a  w  fibroma  mol- 
luscum  cysticum  abdominale.'  The  patient  was  a  widow,  forty 
years  of  age.  She  had  been  married  sixteen  years  before,  and 
had  had  one  stillborn  child  two  years  after  marriage.  She  had 
been  several  times  at  Kreuznach  for  supposed  ovarian  disease, 
and  had  suffered  from  considerable  prolapsus  of  the  posterior 
wall  of  the  vagina.  By  April  ]  875  the  tumour  had  so  much 
increased  that  she  was  tapped  by  Dr.  Kugler  of  Stettin.  A 
large  amount  of  pus  without  odour  came  away,  but  only  partly 
diminishing  the  size  of  the  abdomen.  Finding  on  my  arrival 
a  very  large  abdominal  tumour  only  centrally  fluctuating,  and 
pressing  the  perineum  and  posterior  vaginal  wall  far  down 
between  the  thighs  so  that  I  could  not  ascertain  the  state 
of  the  uterus,  I  was  in  great  doubt  as  to  the  nature  of  the 
case,    but    at    once   proceeded    to    commence    an    exploratory 

i 


114  CASE   OF   FIBROPLASTIC   TUMOUR 

operation.  Dr.  Schonfeld  of  Labes  administered  chloroform, 
and  I  was  ably  assisted  by  Drs.  Kugler  and  Scharlau,  both  of 
Stettin.  After  dividing  the  abdominal  wall  to  the  extent  of 
five  inches  between  the  umbilicus  and  pubes,  some  loose  fat 
was  seen  with  very  large  veins,  one  of  which  was  cut  across  and 
bled  freely.  It  was  secured  by  two  pressure  forceps.  Carrying 
on  the  incision  it  passed  into  the  substance  of  a  solid  tumour 
apparently  glandular  or  fibro-plastic  ;  and  on  pushing  one  finger 
onwards,  a  cavity  was  opened  from  which  some  fifteen  to  twenty 
pints  of  pus  escaped  with  masses  of  yellowish  white  curd-like 
substance.  By  drawing  the  back  part  of  this  cavity  forwards, 
thus  inverting  it  and  pulling  upon  it,  a  large  solid  mass  was 
withdrawn.  It  had  lain  behind  and  to  the  right  side  of  the 
uterus  in  the  loose  cellular  tissue  of  the  pelvis.  Its  connection 
with  the  left  side  of  the  uterus  behind  was  first  tied  and 
divided,  without  interference  with  the  left  ovary  or  tube.  A 
similar  connection  on  the  right  side  was  secured  by  a  clamp 
and  the  tumour  was  cut  away  with  the  right  ovary,  the  fimbria? 
and  part  of  the  right  Fallopian  tube.  Some  other  parts  of  the 
tumour  which  were  deep  in  the  pelvis  behind  the  peritoneum 
were  then  separated  and  removed.  The  clamp  dragging  very 
much  on  the  uterus  and  bladder  it  was  taken  away,  and 
the  included  parts  secured  by  transfixion  and  ligature.  The 
ends  of  the  ligature  were  brought  out  through  a  glass  tube, 
which  was  left  for  drainage  at  the  lower  end  of  the  wound. 
Some  oozing  of  blood  deep  in  the  pelvis  was  stopped  by  torsion. 
The  quantity  of  fluid  removed  was  7  litres,  the  solid  matter 
10^  pounds,  or  about  25  pounds  in  all.  The  glass  tube  caus- 
ing great  pain  it  was  removed  after  three  hours.  A  good  deal 
of  red  serum  had  flowed  through  it  and  came  away  after  its 
removal.  I  left  the  lady  next  day  going  on  well,  and  with  the 
exception  of  some  bladder  trouble  recovery  may  be  said  to  have 
been  uninterrupted.  I  heard  of  her  last  year  as  in  excellent 
health. 

Virchow  speaks  of  this  fibroma-molluscum  as  a  common 
formation  in  the  cellular  tissue  of  the  pelvis ;  but  in  my 
experience  tumours  of  such  character  attaining  a  size  calling 
for  surgical  treatment  are  extremely  rare. 

Tumours  described  as  sub-peritoneal,  myxoma-lipomatodes, 
or    lipoma-myxomatocles,   have    been    observed    in   the    sub- 


HYDATIDS  115 

peritoneal  tissues  and  in  the  mesentery,  and  cases  have  been 
recorded  in  which,  after  removal  of  the  abdominal  tumour, 
relapses  or  secondary  formations  of  similar  structure  have  taken 
place  in  the  neighbouring  glands,  or  in  other  organs  such  as  the 
lungs  or  liver. 

HYDATIDS. 

Hydatids  growing  from  some  part  of  the  peritoneal  surface 
often  acquire  an  enormous  bulk,  and  distend  the  abdominal  walls 
in  proportion.  The  displacement  of  the  viscera,  the  encroach- 
ment on  the  thoracic  region,  and  the  coincident  interference 
with  the  action  of  the  heart  and  lungs,  are  as  marked  as  in 
advanced  cases  of  ovarian  disease.  But  the  history  of  a  case 
of  hydatids  will  commonly  show  that  the  dilatation  commenced 
in  the  upper  part  of  the  abdomen,  extended  next  to  the 
hypochondria,  and,  lastly,  to  the  pelvic  region.  The  growth  of 
hydatids  is  generally  more  rapid  than  that  of  ovarian  cysts. 
There  may  be  similar  irregularities  of  surface  and  contour  felt 
by  pressure,  but  the  interspaces  or  depressions  between  the  pro- 
jecting masses  will  be  more  distinguishable  in  hydatid  disease, 
and  are  sometimes  marked  by  distinct  resonance,  when  portions 
of  distended  intestine  happen  to  be  lying  in  them.  The  abdo- 
minal resonance  is  more  lateral  in  hydatid  disease  than  in  cases 
of  ovarian  tumour,  but  in  both  cases  will  be  limited  to  the  part 
in  which  the  bowels  are  pent  up.  The  fluctuation  in  hydatids 
is  mostly  obscure  and  circumscribed  ;  but  when  it  can  be  felt  the 
hydatid  fremitus  is  decisive.  It  must  after  all  be  remembered 
that  hydatids  may  originate  in  any  part  of  the  peritoneum,  and 
when  they  happen  to  do  so  in  the  region  of  the  broad  ligament 
the  diagnosis  will  demand  additional  circumspection. 

The  best-marked  case  of  hydatids  of  the  peritoneum,  as 
distinguished  from  hydatid  cysts  of  the  liver,  which  I  have 
seen,  was  a  woman  who  was  in  the  Samaritan  Hospital  in 
1870-71.  The  appearance  of  her  abdomen  is  extremely  well 
shown  in  the  drawing,  which  has  been  copied  from  a  photograph 
taken  soon  after  her  admission  to  the  hospital. 

The  abdomen  had  all  the  appearance  of  a  case  of  multilocular 
ovarian  cyst.  Fluctuation  was  very  distinct,  but  the  chief 
peculiarity  of  the  case  was  the  existence  of  numerous  hard 
oodules  scattered  over  different  parts  of  the  abdominal  wall. 

i  2 


116 


CASE    OF   HYDATIDS   OF   PERITONEUM 


They  were  evidently  either  attached  to  the  abdominal  wall  or 
formed  part  of  it,  and  at  first  suggested  the  belief  that  they 
must  be  scattered  nodules  of  cancer.  Some  of  the  best  marked 
of  these  are  shown  on  the  drawing  near  the  umbilicus.  They 
were  quite  as  hard  as  nodules  of  hard  cancer,  and  some  of  them 
being  semi-resonant  gave  rise  to  the  fear  that  they  might  be 
formed  on  the  coat  of  intestine ;  but  the  fact  that  the  disease 
was  of  about  twelve  years'  duration,  that  the  patient  had  borne 
healthy  children  during  its  progress,  that  she  was  not  much 
emaciated,  did  not  suffer  from  sickness  or  diarrhoea,  nor  from 
much   abdominal   pain    nor   tenderness,    showed    that    cancer 


might  be  almost  certainly  excluded  from  the  diagnosis,  even 
before  hydatid  fremitus  was  noticed.  This  was  most  distinct, 
and  the  diagnosis  was  completed  by  the  puncture  of  one  of  the 
nodules  felt  in  the  abdominal  wall  with  a  fine  trocar.  A  little 
clear  fluid  escaped,  in  which  the  hooklets  of  the  echinococcus 
were  distinctly  seen.  No  very  urgent  symptoms  being  present, 
nothing  more  was  done,  and  the  woman  went  home.  She  was 
afterwards  in  the  Middlesex  Hospital  under  Dr.  Murchison, 
who  also  pointed  out  the  hydatid  fremitus  to  his  class.  She 
again  went  home,  and  then,  after  further  enlargement  of  the 


HYDATIDS    WITH    COLLECTION    OF   PUS  117 

abdomen,  and  some  signs  of  chronic  peritonitis,  was  readmitted 
into  the  Samaritan  Hospital,  and  I  determined  to  attempt  the 
removal  of  the  hydatids.  After  making  an  incision  of  three  or 
four  inches  in  length  in  the  median  line  below  the  umbilicus, 
some  free  peritoneal  fluid  escaped,  with  numbers  of  hydatid 
cysts  of  various  sizes,  some  quite  free,  but  most  of  them  having 
some  attachment  to  omentum  or  mesentery.  Several  groups 
of  them  were  removed  with  the  attached  portions  of  mesentery, 
a  few  small  mesenteric  vessels  requiring  ligature.  Between 
three  and  four  pounds  of  these  hydatids,  varying  in  size  from  a 
pea  to  a  small  apple,  were  removed.  Those  in  the  abdominal 
wall  could  not  be  separated,  but  I  punctured  several  of  the 
largest,  hundreds  being  still  left  undisturbed.  The  wound  was 
closed  by  suture.  No  bad  symptom  followed  the  operation  ;  on 
the  contrary,  considerable  relief  was  given.  The  patient  went 
home,  but  I  have  since  ascertained  that  she  died  in  December 
1871.  Some  of  the  groups  of  hydatids  were  shown  at  the 
Pathological  Society  by  Dr.  Murchison,  and  it  was  considered 
at  the  meeting  that  this  was  the  first  instance  in  which  an 
operation  for  the  removal  of  peritoneal  hydatids  had  ever  been 
undertaken  after  the  diagnosis  had  been  correctly  made. 

Although  the  origin  in  this  case  was  not  clear,  it  is  extremely 
probable  that  it  was  from  the  liver.  Hydatid  cysts  of  the  liver 
having  given  way,  the  dispersed  progeny  had  gone  on  multiply- 
ing, and  formed  attachments  in  various  parts  of  the  peritoneum. 

In  another  woman,  thin,  ansemic,  and  of  consumptive  parent- 
age, sent  to  the  hospital  as  a  case  of  ovarian  disease,  I  found 
the  abdomen  considerably  distended,  tender  and  fluctuating, 
the  uterus  small  and  mobile,  pressed  up  forwards  and  behind 
the  pubes,  and  Douglas's  space  occupied  by  an  elastic  tumour. 
The  swelling  was  first  noticed  about  six  months  before  her 
admission,  and  four  pints  of  fluid,  free  in  the  peritoneum,  had 
been  drawn  off  in  the  interim.  She  suffered  much,  but  was 
relieved  by  a  discharge  of  pus  from  the  puncture.  I  made  an 
exploratory  incision,  and  finding  the  adhesions  were  so  close 
that  it  was  impossible  to  make  out  any  cyst  wall,  I  opened  a 
cavity  and  let  out  some  pints  of  fetid  pus.  Then  several  small 
cysts  attached  to  the  omentum  and  mesentery  were  removed,  and 
a  larger  cavity,  apparently  Douglas's  space,  was  discovered  and 
more  pus  evacuated.     A  long  needle  was  passed  up  tli rough 


118  HYDATID    CYSTS   OF   THE   LIVER 

the  posterior  wall  of  the  vagina  for  drainage.  The  discharge  came 
freely  through  the  opening,  but  the  temperature  rose  and  she 
gradually  declined  till  the  sixth  day  of  the  operation,  when  she 
died.  The  intestines,  omentum,  and  other  viscera  were  matted 
together  and  formed  a  sac  containing  thin  purulent  fluid, 
while  the  liver  and  spleen  were  filled  with  hydatids.  There 
was  a  small  cyst  in  the  broad  ligament  on  the  right  side  by 
which  the  uterus  was  drawn  up  in  that  direction,  and  on  the 
left  side  the  ovary  was  masked  and  the  pelvis  blocked  up  by 
numerous  small  cysts  filled  with  hard,  gristly,  calcareous  sub- 
stance evidently  of  hydatid  origin. 

Large  hydatid  cysts  of  the  liver  extending  low  down  in  the 
abdomen,  or  even  into  the  pelvis,  have  frequently  been  mis- 
taken for  ovarian  cysts.  In  one  such  case,  a  young  lady  who 
was  sent  to  me  by  Sir  James  Clark,  I  was  able,  with  the  assist- 
ance of  Sir  William  Jenner,  to  make  an  accurate  diagnosis,  and 
removed  sixty-four  ounces  of  clear  fluid  from  an  hydatid  cyst 
which  projected  downwards  from  the  liver.  Two  years  elapsed 
before  any  of  this  fluid  re-collected.  I  then  tapped  again, 
and  found  only  nine  ounces  in  the  cyst,  the  patient  being 
apparently  well  some  few  months  afterwards.  In  two  similar 
cases,  in  the  Samaritan  Hospital,  emptying  hydatid  cysts  of  the 
liver  by  tapping,  assisted  by  an  exhausting  syringe,  has  been 
followed  by  what  we  may  confidently  hope  is  a  permanent 
cure.  In  another  case,  after  tapping,  the  cyst  suppurated,  its 
contents  decomposed,  the  cyst  became  distended  with  gas,  and 
I  inserted  a  drainage  tube.  Daily  injections  of  iodine  solution 
were  used,  and  the  patient  completely  recovered. 

Such  cases  are  not  likely  to  be  mistaken  for  ovarian  cysts 
by  any  one  conversant  with  the  signs  of  hydatid  diseases  of  the 
liver,  so  well  described  by  Frerichs  and  Murchison.  The  free- 
dom of  the  pelvis  and  hypogastric  region  from  the  presence  of 
a  cyst,  and  the  limitation  of  the  evidences  of  disease  to  the 
upper  part  of  the  abdomen,  are,  of  course,  the  main  points  of 
distinction.  I  have  never  seen  a  case  of  hydatids  in  the  sub- 
stance of  the  ovary,  and  it  is  curious  that  these  organs  seem  to 
be  avoided  as  the  seat  of  parasitic  life,  for  it  is  probable  that 
in  the  reported  cases  it  was  only  by  superficial  attachment  to 
the  peritoneal  covering  that  the  hydatids  had  any  relation  to 
the  ovary. 


DIAGNOSIS  119 


PREGNANCY. 


Certainly  the  most  common  mistakes  in  the  diagnosis  of 
ovarian  tumours  occur  when  the  uterus  is  enlarged  from  some 
cause,  and  pregnancy  is  the  most  common  of  all  causes  of  en- 
largement of  the  uterus.  When  a  patient  has  no  reason  for 
deceiving  her  adviser,  doubt  or  difficulty  will  often  arise  ;  and 
in  cases  of  pregnancy,  real  or  suspected,  the  patient  may  mislead 
the  surgeon  intentionally,  or  from  her  own  hopes  or  fears 
biassing  her  judgment.  An  unmarried  girl,  or  a  married  woman 
whose  husband  is  absent,  or  a  widow,  may  have  very  strong 
reasons  for  concealing  pregnancy,  and  hoping  or  asserting  that 
she  has  an  ovarian  tumour.  Or  a  sterile  wife,  or  one  advanced 
in  age,  suffering  from  a  tumour,  may  have  grounds  almost 
equally  strong  for  hoping  that  she  may  be  pregnant.  A  patient 
was  sent  to  the  Samaritan  Hospital,  supposed  by  an  experienced 
surgeon  to  be  suffering  from  ovarian  tumour,  but  she  denied 
most  positively  the  possibility  of  pregnancy ;  and  after  a  pre- 
mature labour,  probably  brought  on  by  detection  of  the  impos- 
ture, accused  my  assistant,  the  late  Dr.  Eitchie,  who  was  hastily 
called  to  her,  of  having  brought  a  child  which  was  not  hers,  in 
order  to  shield  me  from  the  charge  of  having  made  a  mistake. 
And  in  many  cases  of  ovarian  tumour  patients  have  believed 
themselves  to  be  pregnant,  medical  men  have  been  engaged  to 
attend  upon  them,  and  the  true  nature  of  the  disease  has  only 
been  detected  when  the  natural  period  of  pregnancy  has  long 
passed  over. 

The  diagnosis  between  an  incipient  ovarian  cyst  and 
pregnancy  at  an  early  period  is  really  of  no  practical  import- 
ance. There  is  nothing  to  be  done,  and  the  lapse  of  time 
will  bring  with  it  the  needful  evidence.  In  gestation  the 
proofs  will  be  cumulative  and  the  denouement  decisive.  At  the 
end  of  the  allotted  term,  with  the  exception  of  the  rare  cases  of 
extra-uterine  encysted  conceptions,  the  question  of  pregnancy 
is  excluded,  and  it  becomes  one  of  special  diagnosis.  What  kind 
of  tumour  is  it  ? 

It  would  be  a  work  of  supererogation  to  recapitulate  the 
well-known  indications  of  pregnancy.  But  circumscribed  en- 
largement beginning  and  going  on  without  the  marked  signs 


120  DIAGNOSIS  BETWEEN 

of  pregnancy  leads  to  the  suspicion  of  cystic  growth,  and  to 
turn  this  into  conviction  we  have  to  occupy  ourselves  with  various 
details  connected  with  the  age  of  the  patient,  certain  malfor- 
mations of  the  genital  organs,  the  state  of  the  general  health, 
some  functional  irregularities,  the  progress  of  growth,  the 
configuration  of  the  abdomen,  the  results  of  percussion  and 
auscultation,  and  the  manual  examination  of  the  uterus. 
Certain  limits  of  age  negative  the  possibility  of  conception, 
although  instances  are  recorded  where  girls  between  twelve 
and  fifteen  and  women  up  to  sixty  have  borne  children.  Still, 
the  limits  of  fifteen  and  forty-five  are  very  rarely  passed.  So 
that  in  patients  very  young  or  very  old  the  presumption  must 
be  that  a  voluminous  abdomen  is  the  seat  of  disease.  Again, 
some  malformations  of  the  generative  organs  render  pregnancy 
impossible ;  but  it  must  not  be  forgotten  that  impregnation 
has  been  effected  where  penetration  of  the  vagina  by  any  solid 
body  was  impossible,  and  in  spite  of  procidentia  of  the  uterus, 
and  of  such  diseases  of  the  vagina  and  uterus,  vesico-vaginal 
fistula  or  uterine  cancer,  for  example,  as  might  appear  quite 
inconsistent  with  sexual  intercourse. 

Then  the  size  and  position  of  the  swelling  and  the  duration 
of  its  growth  taken  together  will  influence  the  diagnosis.  A 
tumour  of  nine  months'  certain  duration,  yet  no  larger  than  a 
uterus  at  the  fourth  or  fifth  month,  or  one  of  only  four  or  five 
months'  standing  as  large  as  the  uterus  at  the  close  of  preg- 
nancy, will  not  be  attributed  to  fcetation.  In  the  case  of  a 
tumour  the  history  is  almost  always  that  of  its  discovery  on 
one  side,  and  its  advance  is  more  or  less  regular  according  to  its 
nature,  while  examples  of  the  displacement  of  the  early  gravid 
uterus  are  exceptional. 

It  will  be  found  in  the  majority  of  cases  of  tumour  which 
have  lasted  long  enough,  and  become  large  enough  superfi- 
cially to  simulate  pregnancy^  that  instead  of  the  ordinary 
sympathetic  disturbance  of  the  functions,  the  health  of  the 
patient  has  materially  given  way,  especially  if  the  disease  be 
assuming  a  malignant  form ;  and  that  owing  to  the  comparative 
fixity  of  its  base  of  attachment,  and  from  the  want  of  that 
mutual  adjustment  of  parts  which  mitigates  the  miseries 
caused  by  the  distending  uterus,  more  than  the  natural  amount 
of  discomfort  and  pain  is  encountered.     By  itself,  the  absence 


PREGNANCY  AND  OVARIAN  CYSTS  121 

or  excess  of  the  menstrual  flow  decides  nothing,  and  the  gastric, 
mammary,  and  nervous  symptoms  of  pregnancy  may  also  be  set 
up  by  sympathy  with  the  ovarian  irritation.  In  a  case  where 
the  question  is  between  pregnancy  and  ovarian  disease,  there 
is  hardly  time  for  the  modelling  out  of  the  peculiar  facies 
ovariana,  and  in  fact  no  one  general  symptom  can  by  itself  be 
taken  as  conclusive  ;  though  in  most  of  these  consultations  the 
first  observation  of  a  patient  gives  to  an  experienced  eye  a  right 
impression  as  to  the  real  state  of  matters. 

It  is  very  seldom  that  a  growing  ovarian  cyst,  even  when 
unilocular,  will  leave  the  symmetry  of  the  abdomen  unspoiled. 
The  compound  and  dermoid  forms  are  almost  inevitably  lobu- 
lated,  and  give  rise  to  unseemly  bosses,  with  irregularity  and 
distortion  of  the  contour  and  a  great  difference  in  the  radiating 
measurements  from  the  umbilicus.  The  pointing  or  flattening 
of  the  umbilicus  tells  nothing  as  to  mere  growth,  but  whenever 
the  prominence  is  considerable,  the  ring  open,  the  skin  thin 
and  distended,  there  is  almost  always  fluid  free  in  the  peritoneal 
cavity,  and  the  tumour,  if  any,  which  it  bathes,  is  to  be  other- 
wise recognized. 

The  superficial  veins  of  the  abdominal  wall  are  seldom  so 
much  distended  in  pregnancy  as  they  often  are  with  large 
ovarian  tumours  ;  but  linese  albicantes  are  more  common  in 
pregnancy.  They  are  seen,  however,  over  all  large  tumours  of 
rapid  growth.  When  recent  they  are  of  a  dark  purplish  colour ; 
when  old  they  are  white,  glistening,  or  silvery.  When  the 
abdominal  wall  is  oedematous,  the  lineae  become  very  prominent. 
This  appearance,  common  in  large  solid  or  semi-solid  abdominal 
tumours,  is  rare  in  pregnancy. 

It  is  only  when  the  abdominal  wall  is  very  thick,  or  the  foetus 
misplaced  or  dead,  that  the  heart  sounds  cannot  be  heard 
after  the  sixth  month.  Sometimes  they  are  masked  by  the 
rjlacental  murmur,  a  blowing  sound  synchronous  with  the  beat 
of  the  maternal  heart,  which  is  rarely  absent  in  pregnancy,  but 
is  very  similar  to  a  sound  which  is  common  in  large  fibroids  of 
the  uterus,  but  very  rarely  perceptible  in  ovarian  tumours. 
The  aortic  sound  and  impulse  of  the  mother,  being  perceptible 
both  in  pregnancy  and  in  many  uterine  and  ovarian  tumours, 
are  of  very  little  diagnostic  value. 

Up  to  the  fifth  month  the  pregnant  uterus  gives  no  sense  of 


122  DIAGNOSIS   IN   CASES    OF 

fluctuation ;  it  has  rather  the  consistence  of  a  glandular  or 
fatty  tumour.  After  the  fifth  month  the  sensation  conveyed  to 
the  finger  is  that  of  displacement  of  fluid,  allowing  a  hard  body 
to  be  felt.  This  is  the  foetus,  which  from  the  sixth  to  the 
ninth  lunar  month  may  be  pushed  from  side  to  side.  After 
the  seventh  month  it  is  often  possible  to  trace  the  general  out- 
line of  the  foetus  so  clearly  that  no  mistake  can  be  made.  But 
when  the  abdominal  wall  is  thick,  some  of  the  more  solid 
varieties  of  ovarian  tumour  may  very  closely  resemble  the 
shape  of  a  foetus.  An  ovarian  tumour  surrounded  by  ascitic 
fluid,  or  a  mass  of  small  cysts  projecting  into  a  large  one,  may 
be  moved  very  much  like  a  foetus  in  the  liquor  amnii.  But 
the  independent  movements  of  the  foetus  are  very  characteristic, 
and,  if  felt,  conclusive.  Sometimes,  however,  with  a  living 
child  these  movements  cannot  be  felt ;  and  if  the  child  is  dead, 
of  course  they  cannot  be  made. 

There  are  no  ovarian  tumours  which  give  exactly  the  same 
sensation  as  the  ballottement  of  the  foetus  in  utero,  though 
internal  like  external  ballottement  may  be  simulated  by  a  hard 
tumour  floating  in  ascitic  fluid,  or  by  a  large  cyst  containing 
internal  projections.  The  movements  of  a  cyst  with  a  long 
pedicle  could  hardly  be  mistaken  for  those  of  the  uterus,  as  the 
corresponding  vaginal  touch  will  indicate  its  independence. 
The  effect  which  tumours  mechanically  make  upon  the  position 
and  form  of  the  uterus  do  not  much  resemble  those  of  preg- 
nancy, and  with  the  usually  open  state  of  the  os  in  ovarian 
disease,  nothing  can  invalidate  the  evidence  of  the  sound.  One 
thing,  at  any  rate,  is  certain,  that  in  a  case  of  disputed  preg- 
nancy the  symptoms  can  rarely  be  so  urgent  as  to  require  im- 
mediate operation.  With  the  least  doubt,  therefore,  the  best 
policy  is  to  wait. 

Happily,  cases  of  malplaced  fcetation  are  comparatively 
unfrequent.  It  is  not  clear  which  is  the  most  common  point  of 
attachment  of  the  errant  ovum.  It  is  admittedly  almost  impos- 
sible to  determine  the  portion  of  the  genital  tract  in  which  the 
ovum  is  being  developed  during  the  life  of  the  patient.  Hecker 
states  that  these  pregnancies  are  mostly  abdominal ;  Parry,  that 
he  finds  the  greater  number  recorded  as  tubal.  Wherever  they 
may  be,  and  however  much  they  may  physically  resemble  an 
incipient  ovarian  cyst,  the  early  diagnosis  will  very  much  depend 


EXTRA-UTERINE    FCETATION  123 

upon  the  indications  of  conception.  These  are  absent  in  the  case 
of  ovarian  disease,  and  there  are  not  the  distressing  symptoms, 
such  as  hypogastric  colicky  pains,  vaginal  haemorrhages,  with 
sometimes  discharge  of  decidua,  nor  the  curious  moral  condition 
in  which  the  woman  persistently  believes  herself  enceinte  which 
accompany  these  irregular  foetations.  More  commonly  than 
not,  the  diagnostic  problem  finds  its  solution  in  the  early  death 
of  the  subject.  If  she  should  survive  the  third  or  fourth 
month,  the  probability  is  that  the  gestation  is  abdominal. 
Seventy-six  out  of  132  cases  noted  by  Hecker  escaped.  The 
attention  will  then  be  turned  to  other  matters.  The  detection 
of  the  foetal  form,  its  movements,  ballottement,  the  sounds  of 
the  heart  and  the  placental  murmur  will  at  once  settle  the 
question  of  ovarian  tumour.  Still  later,  or  at  the  full  term,  the 
signs  of  a  spurious  labour,  followed  by  diminution  of  size,  will 
influence  a  decision.  If,  after  this,  the  process  of  encystment 
should  continue,  the  tumour  resulting  may  be  either  fluctuating 
or  solid.  With  an  accumulation  of  fluid  in  the  amnion,  and  con- 
sequently no  diminution  of  size,  one  must  resort  to  abdominal 
ballottement,  with  the  patient  on  hands  and  knees  ;  and  in 
that  position  there  is  no  doubt  the  remains  of  the  foetus  would 
be  felt.  But  between  a  solid  mass  of  a  date  longer  than  the 
nine  months  of  pregnancy  and  an  ovarian  tumour,  judgment 
will  be  mainly  influenced  by  the  absence  of  the  symptoms  of 
pregnancy  during  the  early  stages  of  development,  the  absence 
of  false  labour  at  or  near  the  end  of  the  natural  term,  and  the 
steady  regular  increase  in  size  after  the  usual  period  of  gestation 
has  passed.  Finally,  it  is  self-evident  that  no  ovarian  cyst 
except  a  dermoid  can  come  into  competition  with  one  of  these 
conceptions  which  has  had  the  privilege  of  more  than  half  a 
century  of  incubation,  and  has  degenerated  into  a  substantial 
lardaceous  compound,  or  established  a  claim  to  the  pompous 
appellation  of  lithopaedion. 

The  greatest  difficulty  in  diagnosis  arises  when  the  uterus 
either  undoubtedly  contains  something,  or  is  enlarged  as  in 
pregnancy.  The  so-called  moles  or  hydatids,  which  are  really 
hydatidiform  degeneration  of  the  chorion — intra-uterine  poly- 
pus— cancer  of  the  body  and  fundus  of  the  uterus,  while  the 
cervix  remains  unaffected — haematometra,  hydrometra,  and 
physometra — are  all  conditions  which  must  be  borne  in  mind, 


124  DIAGNOSIS   BETWEEN   OVARIAN   CYSTS 

and  which  may  resemble  ovarian  tumours  in  some  particulars, 
pregnancy  in  others. 

If  the  uterus  instead  of  a  foetus  should  contain  a  mole,  the 
breasts  may  swell,  the  catamenia  cease,  and  all  the  other  signs 
of  pregnancy  may  be  present  for  a  time.  Usually  molar  preg- 
nancy comes  to  an  end  about  the  third  or  fourth  month,  but 
cases  are  on  record  where  it  has  been  protracted  to  the  thirteenth 
and  fourteenth  months ;  and  Churchill  alludes  to  a  case  where 
an  unmarried  woman  had  a  frequent  discharge  of  '  uterine  hyda- 
tids '  throughout  her  menstrual  life.  In  molar  pregnancy  the 
uterus  does  not  enlarge  so  regularly  as  in  ordinary  pregnancy. 
The  enlargement  is  usually  more  rapid,  and  the  functional 
disorders  are  more  intense.  I  once  saw  a  woman  fully  as  large 
as  at  the  end  of  a  normal  pregnancy,  with  a  supposed  ovarian 
cyst.  While  we  were  examining  her  in  the  outpatients'  room, 
uterine  contraction  came  on  ;  and  with  very  little  help  by 
fingers  in  the  vagina  and  pressure  on  the  abdomen,  nearly  a 
whole  pailful  of  these  '  hydatids  '  were  expelled. 

An  intra-uterine  polypus  has  often  been  mistaken  for  preg- 
nancy. After  the  dilatation  of  the  cervical  canal,  and  com- 
mencing expulsion  from  the  or,  it  has  even  been  supposed  that 
abortion  or  labour  was  going  on.  But  it  is  not  likely  that  this 
condition  would  be  mistaken  for  ovarian  disease. 

Cancer  of  the  body  and  fundus  of  the  uterus,  causing  en- 
largement above  while  the  cervix  is  unaffected,  may  be  taken 
for  an  ovarian  cyst  which  is  lying  above  the  uterus,  or  for 
pregnancy.  But  the  general  cachexia,  uterine  discharge,  and 
absence  of  fluctuation  will  be  sufficient  to  distinguish  this  con- 
dition from  ovarian  disease,  and  some  of  the  characteristic  signs 
of  pregnancy  are  certain  to  be  absent. 

Collections  of  blood,  or  retained  clot,  the  so-called  fibrinous 
polypi,  or  of  masses  of  dysmenorrhceal  membrane  with  blood  or 
clot,  all  conditions  described  as  hsematometra,  are  more  likely 
to  be  mistaken  for  pregnancy  than  for  ovarian  disease ;  but 
some  of  the  signs  of  pregnancy  will  certainly  be  wanting,  and 
the  signs  of  enlargement  of  the  uterus  are  sufficient  to  distin- 
guish this  condition  from  ovarian  disease. 

Hydrometra,  again,  is  recognized  by  the  enlargement  of 
the  uterus  without  the  other  characteristic  signs  of  pregnancy, 
before  any  watery  discharge  clears  up  doubt.     Many  supposed 


AND  UTERINE  ENLARGEMENTS  125 

cases  of  hydrometra  have  undoubtedly  been  cases  of  ovarian 
cysts  emptying  themselves  through  the  Fallopian  tube  into  the 
uterus  and  vagina. 

Physometra  is  a  very  rare  condition — generally  the  result  of 
decomposition  of  part  of  a  retained  ovum,  or  of  blood  clot.  The 
resonance  on  percussion  of  the  enlarged  uterus  is  sufficiently 
characteristic. 

Now  bearing  in  mind  the  various  symptoms  and  signs  of 
pregnancy  while  the  uterus  is  still  a  pelvic  tumour,  and  after- 
wards when  the  uterus  has  enlarged,  risen,  and  become  an 
abdominal  tumour,  it  will  be  seen  how  they  resemble  and  how 
they  differ  from  those  which  characterise  ovarian  cysts  and 
tumours,  uterine  tumours,  and  extra-uterine  fcetation. 

When  an  ovary  is  only  slightly  tumefied,  it  usually  lies 
behind  the  uterus  and  may  be  felt  by  vagina  or  rectum,  or 
better  still  by  combined  examination  with  one  finger  in  the 
rectum  and  one  in  the  vagina.  It  does  not  at  all  resemble  the 
enlarging  uterus  of  early  pregnancy.  As  the  ovary  swells,  it 
usually  rises  up  out  of  the  pelvis ;  but  it  sometimes  remains 
low  down  either  from  pressure  or  adhesion,  and  as  it  grows  it 
pushes  the  uterus  either  to  one  side,  or  backwards,  or  forwards. 
It  may  restrict  the  mobility  of  the  uterus,  but  the  independence 
of  the  one  of  the  other  may  generally  be  made  out.  Increasing 
in  size,  it  may  rise  into  the  abdomen  and  leave  the  uterus  quite 
in  its  normal  position,  without  any  deviation  or  modification  of 
mobility,  or  alteration  in  the  cervix,  or  it  may  drag  up  the 
uterus  quite  out  of  reach,  elongating  the  vagina,  so  that  nothing 
but  the  ovarian  tumour  can  be  felt  through  the  vaginal  walls  ; 
or  the  os  may  just  be  reached,  high  up  above  the  pubes  if  the 
ovarian  cyst  is  behind  the  uterus,  or  near  the  promontory  of 
the  sacrum  if  the  cyst  is  in  front.  This  displacement  of  the  os 
backwards  by  a  cyst  in  front  of  it  simulates  pregnancy,  but 
other  signs  are  wanting.  In  case  of  doubt,  delay  of  a  month  or 
two  would  clear  it  up. 

It  is  possible  that  the  rate  of  growth  of  an  ovarian  tumour 
may  closely  resemble  the  rate  of  the  enlargement  of  the  uterus 
in  pregnancy  ;  but  it  is  much  more  likely  to  advance  at  a  very 
different  and  much  less  regular  rate,  and  to  remain  for  weeks  or 
months  without  much  alteration  in  size.     The  foetal  movements 


126  RENAL  CYSTS  AND  TUMOURS 

and  heart  sounds  are  wanting,  and  there  is  probably  a  less  dense 
or  solid,  if  not  a  distinctly  fluctuating  tumour. 

The  distinction  between  pregnancy  and  fibroid  tumour  or 
enlargement  of  the  uterus  will  be  alluded  to  hereafter. 

RENAL   CYSTS   AND   TUMOURS. 

The  diagnosis  of  ovarian  tumours  from  cystic  growths  and 
enlargements  of  the  kidneys  is  made  repeatedly,  in  hospital  and 
private  practice,  with  a  readiness  and  certainty  which  render  a 
mistake  quite  an  exception  in  a  large  number  of  accurate  opin- 
ions. But  exceptions  still  occur ;  and  men  of  great  experience 
must  occasionally  admit  that  an  exact  diagnosis  is  impossible. 
In  other  cases,  it  is  only  after  an  exploratory  or  incomplete 
operation,  or  after  the  death  of  the  patient,  that  a  mistake  is  dis- 
covered, and  the  means  of  avoiding  it  for  the  future  are  learned. 

The  first  case  of  the  kind  which  came  under  my  care  was 
one  of 

Soft  cancer  of  the  right  kidney  in  a  girl  only  four  years 
old.  She  was  sent  up  from  the  country  to  me,  in  1862,  sup- 
posed to  be  suffering  from  ovarian  disease.  Her  appearance  is 
very  well  shown  in  the  woodcut  on  the  opposite  page,  copied 
from  a  photograph,  taken  by  Dr.  Wright  whilst  she  was  in  the 
Samaritan  Hospital. 

The  diagnosis  in  this  case  was  made  without  much  difficulty, 
although  the  urine  was  quite  normal.  The  growth  was  ex- 
tremely rapid ;  hardly  six  months  from  its  commencement  to 
its  fatal  termination — when  the  diseased  mass  weighed  between 
sixteen  and  seventeen  pounds.  The  tumour  occupied  the  whole 
of  the  right  side  of  the  abdomen,  bulging  backwards  in  the 
right  loin.  It  was  uniformly  elastic,  but  no  fluctuation  could 
be  detected.  The  intestines  were  pushed  downwards,  and  to 
the  left  side.  The  rapid  growth,  and  the  absence  of  fluctua- 
tion, were,  of  course,  strongly  against  the  opinion  that  the 
tumour  was  ovarian;  while  the  rarity  of  ovarian  disease  in 
young  children,  and  the  comparative  frequency  of  renal  ence- 
phaloid,  led  to  a  diagnosis  which  was  confirmed  by  a  puncture 
with  a  fine  exploring  needle.  A  few  drops  of  reddish  serum 
were  obtained,  containing  nucleated  cells  of  varied  size  and 
shape.     I  sent  the  child  home,  with  a  note  to  Dr.  Williamson, 


CANCER   OF   KIDNEY 


127 


of  Nantwich,  expressing  my  opinion  that  the  tumour  was  a 
mass  of  soft  cancer,  and  that  the  right  kidney  was  the  most 
probable  seat  of  the  disease.  This  proved  to  be  correct.  Dr. 
Williamson  sent  me  the  specimen,  and  I  exhibited  it  at  the 
Pathological  Society,  in  December  1862.  The  whole  kidney 
was  infiltrated  with  encephaloid.  Although  so  enormously  en- 
larged, the  shape  of  a  normal  kidney  was  distinctly  preserved. 
Its  surface  was  soft  and  elastic,  in  some  spots  giving  a  sense  of 
deep-seated  fluctuation ;  but  no  cyst  was  found,  nor  were  there 


any  marks  of  suppuration  or  haemorrhage.  Coils  of  small  in- 
testine adhered  to  its  inner  and  under  surface.  The  ureter 
was  completely  occluded  by  the  pressure  of  the  tumour.  The 
left  kidney  was  quite  healthy.  Thus  the  normal  condition  of 
the  urine  was  explained.  The  diseased  kidney  added  nothing 
to  the  contents  of  the  bladder,  and  the  healthy  kidney  supplied 
only  normal  urine. 

The  following  remarks  on  this  point  by  Dr.  Eoberts,  of  Man- 
chester (  Urinary  and  Renal  Diseases,  p.  444),  are  well  worthy 
of  serious  consideration.  He  says :  '  The  presence  of  cancer- 
cells  in  the  urine  is  a   sign   which   usually  figures  prominently 


128  CANCER   OF   KIDNEY 

in  the  catalogue  of  symptoms  of  renal  cancer,  but  its  value  is 
very  doubtful.  In  all  the  later  cases,  especially  where  there 
was  hsematuria,  the  urine  was  carefully  examined  for  cancer 
cells,  but  without  success.  Eosenstein  mentions  a  case  in 
which  a  cancerous  villus  was  actually  found  projecting  into  the 
ureter,  yet  no  cancer  cells  could  be  detected  in  the  urine 
during  life.  It  is  by  no  means  an  easy  matter  to  identify 
cancer  cells  in  the  urine,  in  consequence  of  their  similarity  to 
the  transitional  epithelium  of  the  pelvis  and  ureter.  ...  In 
two  examples  of  renal  cancer,  with  hsematuria,  which  I  have 
had  an  opportunity  of  observing,  repeated  and  careful  examina- 
tion of  the  urine  failed  to  discover  the  presence  of  cancer  cells. 
Mr.  Moore  [Med.  Chir.  Trans,  xxxv.  466)  believes  that  he  suc- 
ceeded in  identifying  cancer  cells  in  the  urine  drawn  after 
death  from  the  bladder  of  a  man  in  whose  kidneys  cancerous 
nodules  were  found ;  but  his  description  rather  accords  with 
the  appearance  of  the  epithelial  cells  which  are  always 
freely  detached  from  the  vesical  mucous  membrane  after 
death.' 

Whether  renal  cancer  be  observed  in  children  or  in  adults — 
whether  it  be  or  be  not  accompanied  by  hsematuria,  or  by  the 
presence  in  the  urine  of  albumen,  or  of  epithelial  cells  from 
the  ureter  and  pelvis  of  the  kidney — whether  the  progress  of 
the  disease  be  slow  or  rapid — whether  there  may  be  much, 
little,  or  no  pain,  or  emaciation,  or  gastric  symptoms — or  great 
or  little  effect  upon  the  general  health — the  abdominal  tumour 
is  the  most  prominent  characteristic  of  the  disease.  As  Bright 
observed  (Abdominal  Tumours — Sydenham  Society's  Edit, 
p.  199)  :  '  The  enlargement  shows  itself  much  more  towards 
the  anterior  part  of  the  abdomen  than  towards  the  loins.'  It 
is,  however,  more  or  less  confined  to  one  side  of  the  abdomen 
and  to  the  corresponding  lumbar  region,  whence,  as  a  rule,  it  is 
immovable — and  equally,  as  a  rule,  some  portion  of  the  intes- 
tines are  fixed  in  front  of  it.  But  in  one  extraordinary  case 
an  exception  was  found  to  both  these  rules.  In  the  "  Lancet " 
of  March  18,  1865,  a  case  is  recorded  in  which  an  operation 
was  commenced  for  the  removal  of  a  supposed  tumour  of  the 
left  ovary.  The  patient  was  in  one  of  our  general  hospitals, 
and  it  was  believed  by  the  eminent  physician-accoucheur  who 
carefully  examined  her,  and  by  the  skilful  surgeon  who  performed 


"PYONEPHROSIS    OF    RIGHT    KIDNEY  129 

the  operation,  that  '  the  tumour  was  ovarian,  and  that  from  its 
great  mobility,  and  the  absence  of  adhesions,  its  removal  would 
be  easy.'  Yet  the  uterus  and  ovary  were  found  to  be  healthy, 
and  the  tumour  to  be  the  enlarged  left  kidney  ;  which,  instead 
of  being  fixed,  was  movable — its  peritoneal  covering  being 
elongated  into  a  sort  of  mesentery,  admitting  of  free  move- 
ments— and,  instead  of  pushing  the  intestines  before  it,  the 
descending  colon  and  sigmoid  flexure  were  behind  it.  This 
enlargement  of  a  movable  kidney  added  greatly  to  the  difficulty 
of  diagnosis.  A  movable  kidney  not  enlarged  could  hardly 
be  mistaken  for  an  ovarian  tumour. 

The  absence  of  fluctuation  is  the  leading  sign  by  which  can- 
cerous or  other  solid  tumours  of  the  kidneys  are  distinguished 
from  ovarian  tumours ;  for  it  is  extremely  rare  to  find  a  large 
ovarian  tumour  in  some  part  of  which  fluctuation  cannot  be 
detected.  But  in  some  forms  of  kidney  disease  fluctuation  is 
as  evident  as  in  ovarian  cysts.  It  was  perceptible  in  the  follow- 
ing case  of 

Pyonephrosis  of  the  Right  Kidney,  with  Impaction  of  Two 
Calculi  in  the  Ureter. 

On  May  16,  1865,  I  was  hurriedly  called  to  see  the  mother 
of  a  patient  upon  whom  I  had  performed  ovariotomy  success- 
fully, the  daughter  telling  me  that  her  mother  had  a  tumour 
like  that  which  I  had  removed  from  herself.  I  found  the 
patient  in  excessive  pain  all  over  the  abdomen,  but  greater  on 
the  right  side  and  in  the  right  loin ;  and  I  felt  a  hard  tumour 
between  the  right  false  ribs  and  the  right  ilium,  reaching 
forward  to  within  an  inch  or  two  of  the  umbilicus. 

The  patient  was  so  ill  that  I  could  not  get  any  sort  of 
history  from  her.  I  prescribed  a  full  opiate,  and  directed 
it  to  be  repeated  in  smaller  doses  at  intervals  of  an  hour 
until  the  pain  abated — hot  poultices  being  also  applied.  On 
the  next  day  she  was  much  easier,  and  I  gathered  the  follow- 
ing history. 

She  was  fifty  years  of  age  ;  had  married  when  twenty-two ; 
had  borne  five  children.  Her  last  child  was  seventeen  years 
old.  Before  the  last  confinement  her  health  had  been  very 
good.     Tin's  lnbour  was  very  protracted,  the  presentation  having 

K 


130  CASE   OF    PYONEPHROSIS 

been  transverse.  Ever  since,  she  had  been  subject  at  times  to 
pain  in  the  back  and  right  loin.  It  used  to  come  on  suddenly, 
increase  in  violence,  and  produce  shivering  and  nausea.  After 
six  or  eight  hours  it  would  cease.  Her  urine  at  the  time  of  the 
attacks  was  usually  thick,  with  a  yellowish  sediment ;  at  other 
times  it  was  clear.  For  five  years  such  attacks  recurred  pretty 
regularly  every  six  weeks.  Then,  after  a  more  active  life,  they 
recurred  more  frequently,  scarcely  a  week  intervening  from  one 
to  another.  In  1860  the  catamenia  ceased,  and  the  attacks 
became  milder  and  less  frequent,  and  she  was  entirely  free  for 
a  year  or  more.  In  1862  the  pains  suddenly  recurred  with 
more  violence  than  ever.  After  great  suffering  for  several  hours 
'  a  dozen  or  two  of  little  stones,  as  large  as  a  pin's  head,'  were 
passed  with  the  urine.  From  that  time  to  the  present  attack 
she  had  been  quite  well.  On  May  8,  1865,  while  out  walking, 
she  stumbled  and  fell  upon  her  abdomen.  She  was  lifted  up, 
complaining  of  great  abdominal  pain.  She  got  home,  went  to 
bed,  and  next  day  the  pain  was  so  great  that  she  was  unable  to 
get  up.  During  the  next  six  days  she  passed  a  good  deal  of 
blood  in  the  urine,  and  she  perceived,  for  the  first  time,  a 
tumour  as  large  as  a  cricket  ball  in  the  right  side  of  the  abdo- 
men. On  the  15th  the  pain,  which  had  almost  ceased,  returned 
suddenly  with  great  violence,  and  I  was  sent  for.  She  was 
much  relieved  by  the  opiate  prescribed  ;  and  I  made  a  more 
careful  examination  of  the  tumour.  It  could  be  felt  below  the 
right  false  ribs,  but  its  margins  could  not  be  made  out  very 
distinctly.  They  appeared  to  be  overlapped,  on  the  right  by 
the  caecum,  and  the  left  by  small  intestine.  Wherever  the 
tumour  could  be  distinctly  felt,  it  gave  a  dull  note  on  mode- 
rately strong  percussion,  but  a  clear  one  on  deeper  pressure  and 
sharper  percussion.  By  pressure  forwards  with  one  hand  on  the 
right  loin,  while  the  other  was  on  the  front  of  the  tumour,  a 
trace  of  fluctuation  was  detected.  Pain  was  kept  in  check  by 
opiates,  and  on  May  19th  there  was  a  prominent  point  near  the 
middle  of  the  tumour.  Fluctuation  being  distinct,  I  inserted 
a  very  fine  trocar  at  this  point  (which  was  midway  between 
the  umbilicus  and  right  anterior  superior  spine  of  the  ilium), 
and  drew  off  between  two  and  three  pints  of  thin  pus,  by  a 
syringe  attached  to  the  canula  by  an  air-tight  joint.  The 
urine,  before  the  tapping,  had  been  clear,  but  the  day  after  it 


>  OF    RIGHT    KIDNEY  131 

was  found  by  Dr.  De  Mussy  to  be  loaded  with  pus.  On  the  21st 
the  late  Dr.  Eitchie  reported  that  it  contained  a  large  quantity 
of  pus  altered  by  the  action  of  the  urine.  On  the  27th,  not- 
withstanding this  escape  of  pus  through  the  bladder,  the  tumour 
was  as  large  as  before  the  tapping.  I  therefore  tapped  again, 
and  after  removing  two  pints  of  pus,  left  the  wound  unclosed. 
There  being  no  discharge  after  two  days,  I  inserted  a  laminaria 
tent,  having  re-opened  the  wound  with  the  lancet. 

A  very  free  discharge  went  on  for  the  next  fortnight.  At 
first  it  was  purulent,  but  afterwards  it  consisted  of  clear  fluid, 
which  was  found  to  contain  urea  by  Dr.  Leared.  The  pain 
ceased,  and  the  general  health  rapidly  improved.  The  urine 
became  clear  and  free  from  pus.  On  the  night  of  June  17th 
some  abdominal  pain  came  on,  but  soon  subsided,  and  the 
discharge  from  the  opening  suddenly  ceased.  Urine  was  passed 
with  smarting,  and  was  again  found  to  contain  pus,  mingled 
with  a  little  blood.  Early  in  the  morning  of  June  20th  great 
desire  was  felt  to  pass  water.  After  much  difficulty  and  pain 
a  calculus  of  uric  acid  and  urate  of  ammonia,  as  large  as  a 
broad  bean,  and  much  of  the  same  shape,  was  passed,  and.  was 
soon  followed  by  a  second  of  similar  dimensions.  Eelief  was 
immediate.  On  the  25th  a  boil  was  felt  just  at  the  seat  of  the 
former  punctures.  On  the  27th  it  burst,  discharging  about  two 
ounces  of  grumous  matter.  The  patient  now  felt  so  well  that 
she  was  able  to  walk  about  and  enjoy  herself  in  the  country. 
On  the  1st  of  July  there  was  still  a  little  discharge,  perhaps 
one  ounce  in  twenty-four  hours.  The  abdomen  was  everywhere 
clear  on  percussion ;  but  on  deep  pressure  a  hard  painless  tu- 
mour, as  large  as  an  orange,  was  to  be  felt  in  the  right  loin. 
After  a  few  weeks  this  could  no  longer  be  felt.  She  died  in 
1880  after  several  years  of  good  health. 

This  case  is  in  many  respects  very  instructive.  The  patient 
probably  had  a  tendency  to  deposit  uric  acid  before  her  last 
labour.  The  effects  of  that  protracted  labour  led  perhaps  to 
the  train  of  symptoms  which  ended,  for  a  time,  in  the  passage 
of  numerous  small  calculi.  Then,  in  1863  or  1864,  two  renal 
calculi  began  to  form,  and  set  up  chronic  pyelitis.  The  fall 
in  1865  dislodged  the  calculi,  and  they  blocked  up  the  ureter. 
The  pus  and  urine  accumulated  behind  the  calculi,  and  dis- 
tended  the  pelvis  of  the  kidney  into  the  cavity  from  which  I 


132  CASE   OF   CYSTIC   DEGENERATION 

removed  the  large  quantity  of  pus  at  the  first  tapping ;  and  it 
was  not  till  the  calculi  passed  on  into  the  bladder  and  left  the 
ureter  free  that  the  formation  of  pus  ceased  and  the  artificial 
opening  closed. 

I  have  twice  opened  peri-renal  abscesses  in  the  loin,  and  in 
one  case  removed  a  small  renal  calculus  through  the  opening. 
I  have  cured  a  large  cyst  of  the  right  kidney  by  tapping  through 
the  loin  and  draining.  But  the  case  just  related  is  the  only  one 
in  which  I  have  punctured  the  kidney  through  the  abdominal 
wall.  It  was  a  hazardous  proceeding,  but  the  danger  of  rupture 
of  the  rapidly  increasing  sac  appeared  to  be  so  great,  and  the 
suffering  was  so  excessive,  that  tapping  seemed  to  be  less  dan- 
gerous than  expectation. 

The  following  case  of  Cystic  Degeneration  of  the  Left 
Kidney,  which  was  mistaken  for  a  cyst  of  the  left  ovary,  is  not 
less  instructive : — 

On  October  10,  1866,  a  married  woman,  43  years  of 
age,  called  upon  me  with  a  letter  from  Dr.  M'Donnell,  of 
Stoke  JNewington,  containing  a  very  full  and  accurate  history 
of  her  case.  She  had  been  married  twenty-five  years,  and  had 
nine  children,  the  eldest  being  23  and  the  youngest  four  ye;  rs 
old.  She  had  also  had  one  premature  birth,  and  two  abortions  ; 
the  last  in  1861.     Dr.  M'Donnell  wrote  as  follows:  '  In  April 

1862  she  sought  my  advice  for  a  hard  swelling  situated  in  the 
hypogastric  and  left  iliac  regions,  the  size  of  an  infant's  head. 
Examination  externally,  and  per  vaginam,  convinced  me  it  was 
an  ovarian  tumour.  Mr.  Solly  confirmed  this  opinion  on  May  8, 
1863.  In  1854  and  1855  a  swelling  was  complained  of,  and 
had  been  the  subject  of  conversation  between  husband  and 
wife,  but  no  advice  was  asked  for  at  the  time.  Its  situation 
was  much  as  in  1863.  Aching  pain  was  felt,  from  time  to  time, 
in  the  tumour  without  causing  any  alarm,  from  the  time  when 
it  was  first  noticed  by  the  patient  herself.  It  had  increased  so 
much  in  the  early  part  of  1863  as  to  suggest  the  question  of 
pregnancy.  Some  pain  has  at  times  been  complained  of  in  the 
lumbar  region,  and  the  lower  part  of  the  abdomen,  relieved  by 
leeches,  fomentations,  &c.  Leeches  have  been  applied  several 
times,  the  first  time  in  November   1863.     In  the  summer  of 

1863  the  patient  began  to  attend  the  Hospital  for  Women  in 
Soho  Square,  and  became  an  in-patient  in  January  1866,  with 


OF   THE    LEFT    KIDNEY 


133 


a  view  to  operation,  but  no  operation  was  performed.  She 
remained  in  hospital  twelve  weeks,  her  general  health  being 
then  very  bad,  and  she  was  much  reduced  in  flesh  and  strength. 
After  she  left  the  hospital  the  tumour  increased  in  size,  ex- 
tended to  the  epigastrium,  and  encroached  so  much  on  the 
chest  as  greatly  to  impede  the  breathing,  and  even  prevent 
her  moving  about  in  bed.  Assisted  by  Mr.  Forman,  of  Stoke 
Newington,  on  August  4,  1866,  I  withdrew,  by  tapping  in  the 
linea  alba,  two  gallons  of  dark  discoloured  fluid,  of  the  con- 
sistence of  pea  soup.  The  opening  was  made  midway  between 
umbilicus  and  pubes.  The  operation  was  well  borne ;  the  ab- 
domen was  entirely  freed  from  fluid,  the  resonance  being  tym- 
panitic everywhere,  and  no  solid  tumour  to  be  felt  in  the  pelvis. 
She  recovered  very  favourably,  and  has  been  frequently  out  of 
doors  since  that  time.  The  appetite,  which  had  been  entirely 
wanting  for  months  previously,  became  for  a  short  time  very 
good.  Her  strength  and  spirits  have  much  improved,  though 
the  cyst  has  re-filled.' 

It  was  rather  more  than  two  months  after  this  tapping  when 
I  first   saw  the  patient,  and  I  then  advised  her  to   come  into 
hospital  before  she  became  as  much  dis- 
tressed as  she  had  been  before  the  tap- 
ping.    She  was  admitted  on  December  17, 
1866.     The    tumour   then   occupied  the 
position  shown  in  the  annexed  diagram. 
At  the  upper  and  central  part  there  was 
a  patch  of  crepitus,  giving  the  feeling  of 
adhering  omentum  ;  and  all  down  the  front 
of  the  tumour,  about  an  inch  to  the  left 
of  the  umbilicus,  was  a  cord-like  ridge, 
which  was  taken  by  some  who  examined 

it  for  intestine,  though  it  felt  very  like  a  large,  long,  and 
thick  Fallopian  tube.  The  measurements  were  :  Grirth  at  the 
umbilical  level,  36  inches  ;  from  umbilicus  to  ensiform  cartilage, 
9  inches ;  to  symphysis  pubis,  1\  inches  ;  to  right  ilium,  9 
inches ;  and  to  left  ilium,  9|  inches.  There  was  some  mobility 
in  the  tumour,  both  vertically  and  laterally.  Fluctuation  was 
distinct  across  the  whole  tumour,  in  all  directions*  The  left 
loin  was  dull  on  percussion,  the  right  tympanitic.  The  uterus 
was  high,  the  os  hard  and  fissured,  admitting  the  tip  of  the 


134  SYMPTOMS   AND   OPERATION 

finger  ;  the  cervix  short.  No  part  of  the  tumour  was  below  the 
brim  of  the  pelvis.  The  catamenia  were  expected  in  a  few 
days.  They  recurred  regularly  every  three  weeks — lasting  five 
days.  Dr.  Junker  examined  the  urine  and  reported — '  No 
albumen ;  deposits — urates,  mucus,  and  epithelium.'  She 
was  subject  to  occasional  nervous  attacks,  during  which  she 
was  partially  unconscious.  She  said  they  began  by  palpitation. 
She  had  four  while  in  hospital;  but  they  were  regarded  as 
hysterical,  and  attracted  little  attention.  The  heart  and  lungs 
appeared  to  be  healthy.  The  catamenia  came  on,  and  lasted  a 
week,  ceasing  on  December  29  ;  and  on  January  3,  1867, 
chloroform  having  been  administered  by  Dr.  Junker,  I  made 
an  incision  five  inches  long,  extending  downwards  along  the 
linea  alba,  from  one  inch  below  the  umbilicus.  On  opening 
the  peritoneum,  I  at  once  found  that  the  hard  roll,  or  ridge, 
observed  running  down  the  front  of  the  tumour,  was  part  of  the 
transverse  and  descending  colon,  adhering  closely  by  means  of 
the  meso-colon  and  omentum,  both  to  the  cyst  and  to  the 
abdominal  wall.  I  separated  some  of  these  attachments,  in 
order  to  tap  the  cyst  safely.  On  introducing  the  trocar,  about 
fifteen  pints  of  fluid  escaped.  It  had  the  appearance  of  pea 
soup.  When  the  cyst  was  empty  I  made  some  further  separa- 
tion of  omentum  and  intestine  ;  and  when  passing  my  hand 
round  the  right  side  of  the  cyst,  what  appeared  to  be  another 
cyst  gave  way,  and  between  one  and  two  pints  of  clear  fluid 
escaped.  I  then  found  that  the  deep  attachments  of  the  cyst 
were  too  close  to  admit  of  separation  ;  and  after  tying  three 
vessels  which  were  bleeding  in  the  separated  omentum,  and 
cutting  off  the  ligatures  short,  I  closed  the  wound. 

The  patient  rallied  slowly  from  the  chloroform,  and  com- 
plained of  pain,  which  was  relieved  by  an  opiate.  Two  other 
opiates  were  given  at  night — the  total  quantity  given  amount- 
ing to  50  minims  of  laudanum.  Three  hours  after  operation  a 
small  quantity  of  clear  urine  was  drawn  off  by  the  catheter. 
After  this  not  a  drop  of  urine  entered  the  bladder.  At  10  p.m. 
the  temperature  was  98*4°;  pulse  116;  respiration  28.  The 
next  morning  the  pulse  was  120,  and  very  feeble ;  skin  dry; 
temperature  98° ;  respiration  30.  She  was  comatose,  but 
easily   roused,    and    answered    questions   sensibly.     The    coma 


DESCRIPTION    OF   THE    CYSTIC    TUMOUR  135 

gradually  became  more  profound,  and  she  died  thirty  hours 
after  operation. 

On  examining  the  body  seventeen  hours  after  death  there 
was  no  rigor  mortis.  The  wound  had  united  well.  There 
were  about  four  pints  of  blood-red  serum,  and  a  small  tea-cupful 
of  blood-clot  in  the  peritoneal  cavity.  The  right  kidney  was 
enlarged,  and  very  soft;  the  cortical  substance  very  friable, 
pale  yellow  in  colour.  The  calyces  and  pelvis  were  much 
dilated ;  and  the  thin  sac  formed  by  this  dilatation  had  given 
way  longitudinally.  A  calculus,  weighing  forty  grains,  was  in 
one  of  the  calyces,  forming  a  perfect  cast  of  the  calyx.  The 
bladder  was  contracted  and  empty.  The  uterus  and  ovaries 
were  healthy.  The  left  kidney  formed  the  cystic  tumour, 
which  is  described  as  follows  by  Dr.  Junker : — 

'  The  left  kidney  formed  a  cyst  larger  than  an  adult  head. 
It  presented  one  large  cavity,  composed  of  several  wide  pouches, 
arranged  vertically  at  one  side  of  the  principal  cavity.  The 
stroma  which  formed  the  external  wall  was  of  varying  thick- 
ness ;  thicker  and  stronger  at  the  base  of  the  pouches ;  thinner 
and  less  dense  around  the  main  cyst.  It  had  a  serous  external 
coat ;  at  some  places  hypertrophied,  at  others  atrophied.  Next 
a  fibrous  structure  (fibrous  capsule  of  the  kidney).  This  was 
followed  by  what  appears  to  have  been  the  cortical  substance 
of  the  kidney,  and  from  which  portions  could  be  traced  into 
the  septa  (the  former  columnse  Bertini)  which  separated  the 
pouches  (the  expanded  calyces).  The  main  cyst  (the  original 
pelvis)  was  formed  by  the  peritoneal  and  fibrous  capsules.  The 
medullary  portion  could  not  be  well  distinguished  by  the  naked 
eye  from  the  thickened  lining  membrane.  Thus  the  tumour 
appears  to  be  a  good  specimen  of  genuine  hydronephrosis,  in 
which  pelvis  and  calyces  expand  into  a  large  cavity,  and  pro- 
duce by  pressure  atrophy  of  the  original  structures  of  the  organ. 

1  The  peritoneal  coat  was  rough  with  shreds  of  the  broken- 
down,  extensive,  and  intimate  adhesions.  Some  of  the  neigh- 
bouring organs,  or  portions  of  them,  were  so  intimately  con- 
nected with  the  tumour  that  their  separation  was  impossible, 
and  portions  had  to  be  cut  off  in  order  to  remove  the  cyst. 
Such  connexions  existed  between  the  spleen,  the  head  of 
pancreas,  the  great  curvature  of  stomach,  principally  at  the 


136  HISTORY    OF    THE    CASE 

pyloric  end,  the  duodenum,  a  part  of  the  left  lobe  of  liver, 
coils  of  small  intestine,  omentum  and  mesentery,  and  along 
the  entire  extent  of  the  vertebral  column,  as  low  as  the  second 
lumbar  vertebra  to  these  bodies,  and  their  left  transverse  pro- 
cesses, and  to  the  right  transverse  processes  of  most  of  the 
dorsal  vertebrae.  No  adhesions,  however,  existed  between  the 
tumour  and  the  bladder,  uterus  and  its  appendages,  or  the 
rectum.' 

After  the  information  obtained  by  the  post-mortem  exami- 
nation, I  made  further  inquiry  into  the  history  of  the  case, 
especially  as  to  the  state  of  the  urine,  and  I  learned  from  Mr. 
Scott  that  while  the  patient  was  under  his  care  in  the  Hospital 
for  Women,  in  January  1869,  the  urine  contained  pus  and 
albumen,  was  alkaline,  and  of  low  specific  gravity,  about  1005. 
He  had  '  no  doubt  of  the  tumour  being  ovarian,  but  considered 
the  case  an  unfavourable  one  for  operation,  believing  the  front 
of  the  tumour  was  crossed  by  a  loop  of  intestine  which  would, 
in  all  probability,  be  firmly  adherent  throughout  its  course  ; 
from  the  certainty  of  considerable  adhesion,  in  consequence  of 
the  repeated  attacks  of  inflammation  ;  and  from  the  presence 
of  pus  and  albumen  in  the  urine,  with  a  feeble  circulation. 
The  quantity  of  pus  varied  considerably  during  her  stay  in 
hospital ;  albumen  was  pretty  constantly  present.'  Dr.  M'Don- 
nell  has  ascertained  that,  when  twelve  or  fourteen  years  old, 
she  was  struck  by  an  iron  shovel  with  great  violence  on  the 
abdomen,  near  the  left  ilium.  'She  was  felled  on  the  spot, 
and  remained  insensible  for  some  (indefinite)  time.  She  was 
ill  afterwards,  and  attended  at  St.  Bartholomew's  and  other 
hospitals  for  eighteen  months  as  out  patient.  She  told  her 
husband  that  during  all  this  time  she  "  suffered  much  from  the 
urine,"  but  did  not  explain  more  precisely  the  nature  of  the 
suffering ;  for  four  or  five  years  subsequent  to  the  first  period 
.  of  eighteen  months,  and  for  a  like  period  during  the  first  years 
of  married  life,  she  suffered  pain  and  distress,  referred  to  this 
injury.  Her  pregnancies  were  always  attended  with  distress — 
indeed,  during  her  whole  married  life,  twenty-six  years,  she 
repeatedly  suffered  from  deep-seated  pain  in  the  abdomen 
where  the  injury  was  inflicted.' 

A  single  lady,  59  years  of  age,  first  consulted  me  in   June 
1865.       She    then    had    a    tumour   which    tilled    all    the    left 


DEATH  FROM  RUPTURED  RENAL  CYST  137 

side  of  the  abdomen  and  extended  upwards  under  the  left 
false  ribs.  It  had  been  observed  for  nearly  two  years,  but  its 
increase  had  only  been  rapid  for  about  six  months.  In  August 
1866  fluctuation  was  detected  in  the  upper  part  of  the  tumour, 
and  five  or  six  pints  of  yellowish  pyoid  fluid,  with  mucous 
flakes  floating  in  it,  were  removed  by  tapping.  A  roll  of 
intestine  adhered  to  the  upper  part  of  the  tumour  on  the 
right  side.  Eelief  followed  the  tapping  for  a  time ;  but  a 
second  tapping  was  necessary  in  November.  The  true  nature 
of  the  tumour  then  became  apparent.  The  presence  of  in- 
testine in  front  of  the  tumour,  and  the  limitation  of  the 
tumour  to  the  left  side  of  the  abdomen,  while  the  uterus  was 
freely  movable,  were  the  chief  guides  in  diagnosis,  as  the 
urine  was  normal,  and  there  was  nothing  characteristic  in  the 
fluid  removed  by  tapping.  In  April  1867  the  patient  fell  when 
out  walking,  and  ruptured  the  cyst.  She  died  twenty-eight 
hours  afterwards  ;  and  Dr.  Morton,  of  the  Abbey  Eoad,  found 
a  large  quantity  of  turbid  fluid  in  the  peritoneal  cavity,  corre- 
sponding with  similar  fluid  found  in  a  large  ruptured  cyst  of 
the  left  kidney.  The  renal  tumour  filled  all  the  left  half  of 
the  abdominal  cavity.  Its  lower  end  dipped  down  into  the 
pelvis,  but  was  quite  free.  Its  upper  end  adhered  to  the 
spleen.  The  ruptured  cyst  contained,  besides  the  fluid,  a 
quantity  of  very  thick  viscid  mucus,  and  seven  calculi  of  varied 
chemical  composition.  The  largest  was  an  inch  and  a  half  in 
its  long  diameter ;  the  smallest  was  as  large  as  a  hazel  nut ; 
two  were  smooth  ;  five  were  rough,  and  very  irregular  in  out- 
line. One  calculus  was  loose  in  the  cavity,  as  well  as  a  quan- 
tity of  lithic  acid  gravel.  The  other  calculi  were  imbedded  in 
the  pelvis  and  dilated  calyces.  The  ureter  was  completely 
occluded,  and  no  communication  could  be  found  with  the 
bladder.  The  right  kidney  was  slightly  enlarged.  The  uterus 
and  its  appendages  were  healthy.  The  calculi  are  in  the 
Museum  of  the  College  of  Surgeons. 

The  case  now  to  be  related  shows  the  difficulty  of  diagnosis 
arising  from  the  enormous  bulk  which  effectually  obscured  all 
the  indications  to  be  gathered  from  manipulation,  either  ex- 
ternally or  by  the  vagina.  A  single  woman,  aged  35,  was 
admitted  into  the  Samaritan  Hospital  in  December  1870, 
with   the  abdomen    greatly   enlarged.     The  dimensions  were, 


138  RENAL   CYST 

girth  at  umbilical  level,  60  inches ;  from  ensiform  cartilage  to 
umbilicus,  14  inches;  from  umbilicus  to  symphysis  pubis,  14 
inches  ;  from  right  ant.  sup.  sp.  of  ilium  to  umbilicus,  1 6  inches  ; 
from  left  do.  to  umbilicus,  21  inches.  There  was  extreme 
oedema  of  the  abdominal  walls,  which  were  very  thick,  not 
marked  with  the  linese  albicantes,  and  showed  only  a  few 
dilated  veins.  The  skin  was  red  and  tender,  but  not  painful 
on  pressure.  The  fluctuation  was  scarcely  perceptible,  and 
only  doubtful  in  the  lower  part  of  the  abdomen  ;  there  was  no 
crepitus,  and  the  sounds  on  percussion  were  dull  all  over  the 
swelling.  The  uterus  appeared  to  be  small,  normal  in  size,  and 
movable.  No  tumour  could  be  felt  in  the  pelvis.  Some 
years  ago  she  had  been  treated  with  iodine  for  bronchocele. 
She  said  she  was  pretty  well  a  year  before,  though  she  had 
been  subject  at  times  to  swelling  of  the  body,  which  went  down 
again.  About  Easter  1870  she  began  to  suffer  from  dyspnoea 
and  anasarca  of  the  legs,  and  the  body  was  found  to  be  per- 
manently increasing  in  size.  She  maintained  that  the  dyspnoea 
and  anasarca  preceded  the  abdominal  swelling.  Since  that 
time  she  has  gradually  attained  her  present  size,  with  very 
great  suffering.  The  tumefaction  of  the  abdominal  walls  was 
too  great  to  admit  of  any  satisfactory  diagnosis  as  to  the 
nature  of  the  tumour.  This  could  be  only  ascertained  by  an 
exploratory  incision,  which  was  accordingly  made  between  the 
umbilicus  and  symphysis  pubis  to  the  extent  of  six  inches. 
Much  serous  fluid  escaped,  and  three  or  four  superficial  vessels 
were  tied.  Four  or  five  pints  of  clear  serum  flowed  out  when 
the  peritoneal  cavity  was  opened,  and  a  solid  tumour  was  ex- 
posed, very  firmly  adherent  and  vascular  on  its  surface.  One 
large  vein  at  the  upper  part  bled  so  freely  that,  after  vainly 
trying  to  apply  ligatures  (for  the  soft  granular  tissue  gave  way 
before  the  silk),  I  used  the  actual  cautery  and  solid  perchloride 
of  iron.  The  wound  was  closed  with  sutures  and  long  bands  of 
strapping.  It  did  not  unite  well,  and  after  two  or  three  weeks 
it  opened,  and  allowed  the  tumour  to  protrude  a  little.  There 
was  continued  drainage  of  serum  from  the  gaping  incision,  and 
from  punctures  made  at  various  times  in  the  legs  and  thighs, 
which  relieved  the  urgent  dyspnoea  and  prolonged  life,  but  the 
patient  gradually  got  weaker,  and  died  eight  weeks  after  the 
operation. 


SYMPTOMS  139 

The  tumour  was  found  adherent  to  the  abdominal  walls,  to 
the  liver,  omentum,  and  descending  colon.  Behind,  it  was 
inseparably  connected  with  the  right  kidney,  which  had  to  be 
removed  with  it.  The  tumour  alone  weighed  eighty-four 
pounds.  The  uterus  and  both  ovaries  were  healthy.  Dr. 
Wilson  Fox  reported  that  the  tumour  was  '  fibro-plastic,'  that 
the  right  kidney  could  only  be  separated  from  it  by  careful 
dissection,  and  that  it  probably  originated  in  the  kidney,  or  in 
the  peritoneum  covering  it.  Portions  of  the  tumour  are  pre- 
served in  the  Museum  of  University  College. 

Another  case  of  great  practical  interest  is  that  of  a  girl  in 
her  sixteenth  year,  who  was  sent  to  me  by  Dr.  Wardell,  of 
Tunbridge  Wells,  on  account  of  an  abdominal  tumour.  She 
was  a  fat,  florid  girl,  and  apparently  in  robust  health  ;  but  her 
abdomen  began  to  enlarge  when  she  was  about  twelve  years 
old,  and  went  on  increasing,  not  attracting  any  particular  notice 
till  May  or  June  1871,  when  she  was  seized  with  some  pain  on 
the  right  side.  This  lasted  only  a  few  hours,  and  was  followed  by 
swelling,  also  on  the  right  side,  which  disappeared  after  some 
days'  rest,  the  general  enlargement  remaining.  Dr.  Wardell  first 
wrote  to  me  about  her  in  October  1871.  A  month  later  he  wrote 
that  the  tumour  was  enlarging,  and  she  was  admitted  into  the 
Samaritan  Hospital  early  in  December.  On  December  15, 
the  girth  at  the  umbilical  level  was  35  inches,  distance  from 
sternum  to  pubes  15  inches,  and  from  one  ilium  to  the  other, 
across  the  front  of  the  abdomen,  15\  inches.  Fluctuation  was 
distinct  all  over  the  lower  part  of  the  abdomen,  and  the  move- 
ment of  a  cyst  was  distinctly  visible  between  the  umbilicus  and 
sternum— rising  and  sinking  with  the  respiratory  movements — 
the  upper  border  of  the  cyst  being  about  half-way  between  the 
sternum  and  the  umbilicus.  On  both  sides  of  the  abdomen 
the  sound  was  dull  on  percussion ;  so  it  was  from  the  pubes 
to  within  two  inches  of  the  umbilicus.  From  thence  to  the 
upper  border  of  the  cyst  in  the  centre  it  was  resonant  or  tym- 
panitic, and  on  pressure  with  the  fingers  the  peculiar  gurgling 
and  contraction  of  intestine  could  be  felt.  It  was  quite  clear, 
therefore,  that  we  had  intestine  adhering  in  front  to  the  upper 
part  of  the  cyst.  Both  loins  and  flanks  were  clear  on  percus- 
sion, the  right  more  distinctly  so  than  the  left.  The  uterus 
was  normal    in   size  and   situation.     On  the  right  side  of  the 


140       EXPLORATORY    INCISION    FOLLOWED    BY    UREMIC    FEVER 

vagina  a  soft  fluctuating  mass  (the  lower  part  of  the  cyst) 
could  be  felt  just  above  the  brim  of  the  pelvis.  The  catamenia 
appeared  when  she  was  fourteen,  and  continued  regular  for 
four  months,  then  ceased  for  four  months,  and  since  then  have 
been  regular,  but  rather  excessive,  lasting  a  week.  There  was 
some  irritability  of  bladder.  Very  unfortunately,  owing  to  a 
mistake,  the  urine  was  not  examined. 

The  girl  was  kept  in  hospital,  and  on  January  23,  1872,  the 
girth  had  increased  to  thirty-seven  inches,  and  each  of  the  other 
measurements  showed  an  increase  of  about  an  inch.  The 
presence  of  intestine  in  front  of  the  cyst  led  to  the  suspicion  of 
hydronephrosis ;  but  the  resonance  of  both  loins,  and  the  fact 
that  the  cyst  could  be  felt  by  the  vagina  on  the  right  side, 
almost  negatived  this  suspicion,  and  it  appeared  more  probable 
that  we  had  to  deal  with  a  multilocular  ovarian  cyst,  to  which 
intestine  adhered  in  front.  I  made  an  exploratory  incision  on 
January  24,  and  at  once  came  upon  the  caecum,  its  appendix, 
and  the  ascending  colon,  which  had  been  pushed  upwards  and 
across  the  median  line  by  the  cyst,  which  was  behind  it.  I  saw 
at  once  I  had  to  deal  with  a  hydronephrosis  ;  so,  pushing  aside 
the  intestine,  I  tapped  the  cyst.  Twelve  pints  of  fluid  escaped 
through  the  canula,  and  I  then  found  that  the  uterus  and  both 
ovaries  were  healthy.  When  the  cyst  was  empty,  I  fixed  the 
opening  in  its  wall  to  the  abdominal  wall  by  a  harelip-pin,  and 
then  closed  the  wounds  by  sutures.  A  small  cyst  in  each 
broad  ligament  I  felt,  but  did  not  disturb. 

The  fluid  removed  from  the  cyst  was  clear,  light  yellow  in 
colour,  with  a  faint  urinous  odour,  acid  reaction,  and  specific 
gravity  of  1006.  On  standing,  a  few  flocculent  clouds  formed, 
and  some  red  blood-corpuscles  were  deposited.  On  careful 
chemical  examination,  urea,  urates,  and  chlorides  were  found 
in  about  the  normal  proportions  of  healthy  urine.  There  were 
traces  of  uric  acid.  A  very  small  amount  of  albumen  and  phos- 
phates, but  no  traces  of  sugar  could  be  detected.  On  micro- 
scopic examination  of  the  deposit  large  numbers  of  red  blood- 
corpuscles  were  seen,  a  few  pus  cells,  some  squamous  epithelial 
cells,  and  granular  cells,  but  neither  tube-casts  nor  crystals. 

The  case  so  far  as  it  assists  in  the  study  of  diagnosis  might 
end  here,  but  the  fever  which  followed  the  operation  and 
caused  her  death  on  the  fourth  day  was  so  remarkable  that  I 


SUMMARY    OF    DIAGNOSIS    OF    RENAL    CYSTS  141 

may  refer  those  interested  in  the  subject  to  a  lecture  on  the  case 
which  was  published  in  April  1872,  in  the  '  Medical  Times  and 
Gazette.' 

It  is  evident  from  the  cases  just  narrated  that  both  solid 
and  cystic  tumours  of  the  kidney  may  be  mistaken  for  ovarian 
tumours.  Solid  renal  tumours,  whether  cancerous  or  innocent, 
may  resemble  the  malignant,  pseudo-colloid,  or  cysto-sarcoma- 
tous  tumours  of  the  ovaries  ;  while  different  varieties  of  ovarian 
cysts  may  be  closely  simulated  by  different  forms  of  pyelitis 
and  pyonephrosis,  hydronephrosis,  cystic  degeneration,  and 
the  growth  of  hydatids  in  the  kidney.  Perhaps  the  diag- 
nosis may  be  facilitated  by  attention  to  the  following  proposi- 
tions : — 

1.  Although  intestine  is  sometimes  found  in  front  of  ovarian 
tumours,  and  sometimes  behind  movable  renal  tumours,  these 
are  very  rare  exceptions  to  the  general  rule  that  renal  tumours 
press  the  intestines  forward,  and  ovarian  tumours  press  them 
backward.  In  other  words,  ovarian  tumours  are  in  front  of  the 
intestines,  renal  tumours  are  behind  the  intestines. 

2.  Large  tumours  of  the  right  kidney  usually  have  the  as- 
cending colon  on  the  inner  border  of  the  tumour.  Tumours  of 
the  left  kidney  are  usually  crossed  from  above  downwards  by 
the  descending  colon. 

3.  The  discovery  of  intestine  in  front  of  a  doubtful  abdomi- 
nal tumour  should  lead  to  a  careful  examination  of  the  urine. 
It  is  possible  that  one  kidney  may  be  diseased  and  the  urine 
quite  normal,  because  the  healthy  kidney  alone  secretes  urine. 
But  the  rule  is  that  either  blood,  pus,  or  albumen,  or  charac- 
teristic epithelium,  is  detected — or  some  history  may  be  elicited 
of  their  having  been  detected  at  some  former  period. 

4.  If  any  doubt  be  entertained  whether  a  substance  felt 
between  an  abdominal  tumour  and  the  integument  be  or  be 
not  intestine,  percussion  will  not  always  solve  the  doubt,  because 
the  intestine  may  be  empty  and  compressed.  But  (a)  an 
intestine  when  rolled  under  the  fingers  contracts  into  a  firm, 
cord-like,  movable  roll ;  (b)  the  patient  may  be  conscious  of 
the  gurgling  of  flatus  along  it,  or  the  gurgling  may  be  heard 
on  auscultation ;  (c)  the  intestine  may  be  distended  by 
insufflation,  after  passing  a  long  elastic  tube  through  the 
vi'cA  uni. 


142  SUMMARY    OF    DIAGNOSIS   OF   RENAL   CYSTS 

5.  Ovarian  and  renal  cysts  may  both  be  subject  to  great 
alterations  in  size.  When  the  kidney  is  the  seat  of  disease  the 
fluid  usually  escapes  by  the  ureter  and  bladder.  An  ovarian 
cyst  can  only  empty  itself  through  the  bladder  after  adhesion 
and  a  fistulous  opening.  It  may  discharge  through  the  Fal- 
lopian tube  and  uterus,  or  into  an  intestine,  or  through  the 
coats  of  the  vagina.  In  either  case  the  physical  and  chemical 
characters  of  the  fluid  discharged  will  be  the  chief  guide  in 
diagnosis. 

6.  If  a  correct  history  can  be  obtained,  it  may  be  expected 
that  a  renal  tumour  has  first  been  detected  between  the  false 
ribs  and  ilium,  and  that  it  has  extended  first  toward  the  um- 
bilicus, next  into  the  hypochondrium,  and  lastly  downwards 
towards  the  groin.  An  ovarian  tumour  has,  in  all  probability, 
been  first  noticed  in  one  inguinal  or  iliac  region,  and  has 
extended  upwards  and  inwards. 

7.  It  is  only  a  very  small  ovarian  tumour,  with  a  long 
pedicle,  which  could  be  mistaken  for  a  floating  or  movable 
kidney.  The  latter  may  be  recognised  by  its  characteristic 
shape,  though  it  is  often  so  misplaced  that  the  hilus  is  turned 
upwards.  The  kidney  is  usually  felt  between  the  umbilicus 
and  the  false  ribs,  and  may  be  pushed  upwards  and  downwards, 
or  laterally,  to  a  varying  extent,  or  into  the  lumbar  region  to 
the  normal  position  of  the  kidney.  When  the  kidney  is  pushed 
away  from  this  position,  the  sound  on  percussion  becomes  tym- 
panitic. 

8.  Just  as  renal  tumours  are  usually  associated  with  some 
evidence  or  history  of  hematuria,  calculus,  albuminuria,  ne- 
phritic colic,  or  some  notable  change  in  the  quantity  or  state 
of  the  urine,  so  ovarian  tumours  are  usually  associated  with 
some  change  in  the  quantity  and  regularity  of  the  discharge, 
or  with  suffering  at  the  catamenial  periods,  and  with  some 
alteration  in  the  mobility  or  situation  of  the  uterus.  But  as 
in  some  rare  cases  of  renal  disease  the  urine  may  be  normal,  so 
in  some  rare  cases  of  ovarian  disease  there  may  be  nothing 
abnormal  to  be  discovered  in  any  of  the  pelvic  viscera,  nor  in 
their  functions. 

By  bearing  these  facts  in  mind  an  accurate  diagnosis  may  be 
made  in  a  very  large  proportion  of  cases.  Some  rare  cases  of 
exceptional  difficulty  may,  however,  be  occasionally  expected. 


f  DISTENDED    BLADDER  143 

Not  as  any  excuse  for  the  careless  or  ignorant,  but  as  some 
solace  to  others  who  have  erred  unwittingly,  and  as  an  answer 
to  some  who,  having  little  experience  of  the  difficulties  of 
actual  practice,  are  apt  to  speak  of  all  mistakes  as  inexcusable, 
I  quote  the  following  remark  of  one  of  the  greatest  clinical 
teachers  of  any  age  or  country — Bright :  '  I  have  known  the 
enlarged  kidney  to  be  mistaken  for  disease  of  the  spleen — of 
the  ovary — of  the  uterus — and  for  a  tumour  developed  in  the 
concave  part  of  the  liver  ;  nor  is  it,  perhaps,  possible,  by  the 
greatest  care  and  the  most  precise  knowledge,  altogether  to 
avoid  such  errors.' 

DISTENDED   BLADDER. 

Before  dismissing  the  subject  of  renal  cysts,  a  word  of  caution 
may  not  be  superfluous,  reminding  the  young  practitioner  that 
the  bladder,  distended  with  urine,  has,  in  several  recorded  in- 
stances, formed  an  abdominal  tumour,  which  has  been  mistaken 
either  for  an  ovarian  cyst,  or  for  ascites,  and  has  been  tapped, 
in  some  cases  with  a  fatal  result.  I  was  once  accidentally  pre- 
sent in  an  hospital  when  a  woman  was  about  to  be  tapped. 
The  peculiar  projection  immediately  above  the  pubes  at  once 
struck  me,  and  I  suggested  that  the  catheter  should  be  in- 
troduced. Five  pints  of  urine  passed  through  the  catheter, 
and  the  tumour  disappeared.  In  this  case  the  patient  was 
supposed  to  be  suffering  from  incontinence  of  urine  from  pres- 
sure of  the  imaginary  cyst,  the  urine  which  dribbled  away 
being  simply  overflow  from  the  paralysed  bladder.  As  in  any 
case  the  use  of  the  catheter  will  set  every  doubt  at  rest,  it 
is  useless  to  say  more  than  that  distension  of  the  bladder  is 
of  common  occurrence  both  in  uterine  and  ovarian  tumours 
which  are  fixed  in  the  pelvis.  In  some  cases  it  is  only  by  the 
use  of  a  small  and  long  elastic  catheter  that  the  bladder  can  be 
reached  and  emptied.  This  is  especially  necessary  in  cases  of 
uterine  tumour,  where  it  is  not  rare  to  find  the  bladder  drawn 
up  nearly  to  the  level  of  the  umbilicus. 

F^CAL   ACCUMULATIONS. 

In  his  '  Clinical  Lectures  on  the  Diseases  of  Women,' 
Dr.  Simpson  says  that  there  had  been  '  in  the  hospital  a 
patient  who  was  sent    from    the    country,    and    presented    on 


144  FvECAL    ACCUMULATION 

admission  the  colour  and  appearance  of  a  person  labouring 
under  some  malignant  disease.  The  facial  expression  might 
have  led  you  to  believe  that  she  was  the  subject  of  a  cancer- 
ous diathesis.  She  had  a  tumour  in  the  left  hypogastric 
region,  about  the  size  of  a  fist.  But  under  the  use  of 
croton  oil  it  readily  disappeared,  and  proved  to  be  only  a 
mass  of  fasces  in  the  colon.  You  might  suppose  that  it  would 
be  difficult  to  mistake  such  a  tumour  for  any  kind  of  morbid 
growth,  and  you  might  imagine  that  the  patient  would  be 
suffering  from  such  a  degree  of  constipation  as  at  once  to 
indicate  its  real  nature.  But  there  is  not  of  necessity  any 
degree  of  constipation  present.  On  the  contrary,  there  is 
sometimes  diarrhoea^  Dr.  Abercrombie  told  me  he  once 
attended,  with  some  other  physicians,  a  case  where  there 
were  large  swellings  felt  in  the  abdomen,  and  the  patient 
suffered  severely  from  diarrhoea.  After  death  the  swellings 
were  found  to  be  formed  merely  by  hardened  deposits  of  faecal 
matter  in  the  sacculi  of  the  large  intestine,  the  central  tract 
through  the  bowel  being  left  free ;  and  that  he  was  then  in 
attendance  upon  a  patient  suffering  from  obstinate  diarrhoea, 
who  at  the  same  time  had  large  scybalous  masses  accumulated 
in  the  colon.  And  you  can  readily  understand  how  large  col- 
lections of  hard  faecal  matter  lying  long  in  any  part  of  the 
large  intestine  should  at  length  give  rise  to  such  an  amount 
of  irritation  there  as  to  produce  an  attack  of  diarrhoea ;  and 
when  this  has  become  established,  the  original  cause  of  it  will 
readily  be  overlooked.  The  peculiar  feeling  of  such  a  tumour 
will  generally  enable  you  to  decide  as  to  its  true  character :  it 
feels  like  no  tumour  that  I  know  of.  On  being  examined  either 
through  the  abdominal  walls  or  through  the  rectum,  it  is  felt 
to  be  hard  and  resistant ;  but  if  one  finger  be  pressed  steadily 
upon  it  for  one  or  two  minutes,  it  will  at  last  indent  like  a  hard 
snowball,  and,  as  there  is  not  the  slightest  elasticity  about 
it,  the  indentation  remains  after  the  pressure  is  removed.  If 
any  doubt  should  still  remain,  the  persevering  use  of  aperients 
will  clear  up  for  you  the  diagnosis  by  causing  the  mass  to  be 
dissolved  and  carried  off.' 

Although  I  have  several  times  seen  lumps  in  the  region 
of  the  caecum  and  different  parts  of  the  ascending  colon,  which 
were  clearly   faecal  accumulations,  yielding  to  the  pressure  of 


PELVIC   CELLULITIS   AND   ABSCESS  145 

the  finger,  and,  owing  to  their  containing  or  being  surrounded 
with  gas,  having  a  certain  degree  of  resonance  on  percussion, 
yet  I  have  only  once  met  with  one  of  such  a  size  as  to  be  mis- 
taken for  an  ovarian  tumour. 

This  was  a  very  remarkable  case,  which  1  saw  with  Dr. 
Waters,  of  Chester.  I  was  summoned  by  telegraph  to  Chester, 
and  on  arriving  there  found  for  the  first  time,  owing  to  a  postal 
delay,  that  it  was  one  of  obstructed  intestine.  Stercoraceous 
vomiting  had  been  going  on  for  many  days,  and  the  lady  was 
almost  moribund.  The  abdomen  was  distended  beyond  the 
ordinary  size  at  the  full  time  of  pregnancy,  and  apparently  by  a 
well-defined  solid  tumour,  which  I  should  have  imagined  to  be 
uterine  or  ovarian  but  that  it  was  semi-resonant  on  percussion. 

Consulting  with  Dr.  Waters  as  to  the  performance  of 
Amussat's  or  Nelaton's  operation,  I  thought  it  better  rather  to 
commence  by  an  exploratory  incision  as  in  ovariotomy,  in  order 
to  ascertain  what  the  abdominal  tumour  really  was.  On  divid- 
ing the  peritoneum  the  tumour  at  first  sight  appeared  exactly 
like  a  very  large  uterus,  but  on  passing  my  hand  under  its 
lower  border  I  found  the  uterus  and  both  ovaries  healthy. 
On  percussing  the  tumour  there  was  sufficient  resonance  to  show 
that  it  was  either  intestinal  or  a  cyst  containing  some  air,  and 
further  examination  convinced  me  that  it  was  the  csecum  and 
colon  enormously  distended.  I  accordingly  performed  a  modi- 
fied Nelaton's  operation,  first  stitching  the  peritoneal  coat  of 
the  caecum  to  the  peritoneal  edges  of  the  incision  in  the  abdo- 
minal wall  and  then  opening  the  gut.  More  than  two  pailfuls 
of  semi-solid  fsecal  matter  escaped,  and  the  gut  rapidly  con- 
tracted as  it  became  empty.  I  could  not  ascertain  what  the 
cause  of  the  obstruction  had  been.  The  patient  perfectly 
recovered,  and  some  months  afterwards  I  closed  the  artificial 
anus,  after  paring  the  edges,  by  stitching. 

PELVIC   CELLULITIS   AND    ABSCESS. 

Since  the  subject  of  pelvic  cellulitis  has  been  studied,  and 
the  effects  of  the  effusion  of  serum  and  of  lymph  in  the  loose 
cellular  tissue  of  the  broad  ligaments  and  neighbourhood  of 
the  uterus,  followed  by  the  formation  of  pus  and  its  discharge 
either  spontaneously  or  by  surgical  assistance,  have  become 
generally  understood,  it  is  not  often  that  ovarian  tumours,  even 

L 


146  PELVIC   ABSCESS 

when  they  are  confined  below  the  brim  of  the  pelvis,  are  mis- 
taken for  pelvic  cellulitis  or  abscess.  But  it  is  very  probable 
that  many  of  the  recorded  cases  of  supposed  cures  of  ovarian 
or  uterine  tumours  were  merely  instances  of  inflammatory 
exudations  into  some  part  of  the  pelvic  cellular  tissue,  which 
were  either  removed  by  absorption  or  terminated  in  suppura- 
tion and  the  discharge  of  the  pus,  either  by  the  rectum,  vagina, 
bladder,  or  skin.  In  1871  I  saw  a  lady  who  had  been  sup- 
posed to  suffer  from  ovarian  disease,  in  whom  a  pelvic  abscess 
discharged  not  only  through  the  rectum,  the  bladder,  the 
vagina,  and  in  one  loin,  but  gravitating  down  the  leg,  opened 
in  the  calf.  A  suppurating  ovarian  cyst  might  possibly  end  in 
the  same  way,  but  the  history  of  the  case,  the  severe  pain,  the 
high  temperature  at  the  onset  of  the  disease  before  any  con- 
siderable tumour  had  formed,  the  remarkable  almost  bonelike 
hardness  and  fixity  of  the  swelling,  as  if  inseparably  connected 
with  one  or  other  ilium,  and  the  flexure  of  the  thigh  from  the 
way  in  which  the  psoas  muscle  is  involved,  are  sufficiently 
characteristic.  It  is  very  seldom  that  an  ovarian  cyst  shows 
any  tendency  to  point  in  the  situation  where  there  is  the 
greatest  tendency  to  point  in  pelvic  abscess,  that  is  in  the  roof 
of  the  vagina,  very  near  the  cervix  uteri,  either  behind  or  in 
front  or  to  one  side  of  it.  An  ovarian  cyst  or  a  pelvic  abscess 
which  had  burst  into  the  peritoneal  cavity  would  be  necessarily 
attended  by  the  same  symptoms  as  perforating  peritonitis.  But 
in  one  case  the  previous  history  would  have  been  that  of  pelvic 
cellulitis,  in  the  other  that  of  an  ovarian  cyst  which  had  become 
inflamed.  It  is  seldom  that  a  pelvic  abscess  extends  upwards 
above  the  umbilical  level.  Hardness  may  be  felt  in  one  or 
other  iliac  region  or  above  the  pubes,  and  a  corresponding 
hardness  or  swelling  may  be  felt  by  the  vagina,  behind  or  in 
front  or  to  one  side  of  the  uterus ;  and,  if  pus  have  formed, 
fluctuation  may  be  detected.  An  ovarian  cyst  is  not  so  firmly 
fixed  in  the  pelvis ;  even  if  adherent  there  it  does  not  give  the 
same  impression  of  close  attachment  to  the  pelvic  bones.  It 
rarely  leads  to  such  troublesome  dysuria,  to  such  rectal  pain 
or  tenesmus,  to  such  constant  throbbing,  or  to  such  enforced 
quiescence  of  the  lower  limbs ;  and  the  general  outline  of  an 
ovarian  cyst  can  be  more  easily  traced  than  the  diffuse  bulging 
of  a  pelvic  abscess.     The   swelling  in  pelvic   abscess  is  harder, 


HEMATOCELE  147 

more  painful  on  pressure,  and  accompanied  with  nervous  pains 
such  as  are  usually  called  sciatica  or  pelvic  neuralgia.  It  is 
not  often  that  an  ovarian  cyst  suppurates  until  it  has  existed 
for  some  time,  or  has  attained  a  large  size  ;  but  the  whole 
course  of  a  pelvic  abscess,  from  its  commencement  till  the 
discharge  of  pus  is  effected,  is  seldom  more  than  from  three  to 
four  weeks. 

HEMATOCELE. 

As  in  pelvic  cellulitis,  so  in  hagmatocele,  it  is  only  a  small 
ovarian  tumour  which  has  not  risen  out  of  the  pelvis,  or  a  large 
ovarian  cyst  which  has  suppurated,  that  could  be  mistaken  for 
either  the  early  and  small  or  the  later  and  large  stages  of  pelvic 
cellulitis  or  hasmatocele.  A  small  hsematoceie  in  the  early  stage 
produces  much  the  same  local  conditions,  is  accompanied  by 
very  similar  pain,  and  almost  as  much  general  fever  as  pelvic 
cellulitis,  and  is  apt  to  be  associated  with  about  the  same 
amount  of  pelvic  peritonitis.  Indeed,  it  is  very  probable  that 
many  of  the  cases  of  pelvic  cellulitis  take  their  origin  from 
a  hsematoceie.  Some  blood  escapes  into  the  loose  cellular 
tissue  in  the  neighbourhood  of  the  uterus  about  the  time  of 
menstruation ;  a  clot  forms,  does  little  harm  by  itself,  but 
pelvic  cellulitis  is  set  up,  which  becomes  the  more  grave  con- 
dition, and  ends  in  abscess,  the  clot  which  excited  it  disappear- 
ing. It  is  only  when  the  effusion  of  blood  is  large  and  sudden, 
its  escape  through  the  Fallopian  tube  prevented,  and  its  general 
diffusion  in  the  peritoneal  cavity  limited  by  peritonitis  and 
adhesions,  that  a  distinct  pelvic  or  abdominal  tumour  is  formed. 
It  is  only  rarely  tha/t  such  a  tumour  extends  as  high  up  as  the 
umbilical  level ;  much  more  frequently  it  is  either  within  the 
pelvis,  behind  or  to  one  or  other  side  of  the  uterus,  and  barely 
to  be  felt  through  the  abdominal  wall.  These  characters  are 
quite  sufficient  to  distinguish  it  from  a  large  ovarian  cyst. 
Small  ovarian  cysts  do  not  commence  so  suddenly,  are  not  so 
closely  associated  with  the  catamenial  period,  nor  is  their  advent 
ushered  in  by  such  acute  pain  or  febrile  disturbance.  An 
ovarian  cyst  is  seldom  dangerous  to  the  life  of  the  patient 
before  it  has  attained  considerable  size,  whereas  a  hsematoceie 
of  very  moderate  extent  and  of  sudden  formation  may  be  either 
rapidly  fatal  or  lead  to  very  dangerous  symptoms. 

i.  2 


148  CASE   OF   HEMATOCELE 

The  following  narrative  may  serve  to  illustrate  the  above 
remarks,  and  I  have  seen  several  similar  cases.  A  young 
lady  was  travelling  from  Paris  to  London.  Before  she  reached 
Calais  the  menstrual  discharge  commenced.  Between  Calais 
and  Dover  she  was  wet,  cold,  and  sea-sick.  Before  she  reached 
London  the  discharge,  which  had  begun  freely,  stopped  en- 
tirely ;  she  was  in  severe  pain,  and  feeling  extremely  ill.  Dr. 
Priestley  was  consulted  next  day,  and  found  considerable  swell- 
ing in  the  right  iliac  region,  with  extreme  tenderness  on  pres- 
sure. A  high  degree  of  fever  and  restlessness,  with  increase  of 
the  local  swelling,  and  an  absence  of  menstrual  discharge,  were 
the  principal  symptoms  for  the  few  succeeding  days.  Then 
some  reaj)pearance  of  uterine  haemorrhage  was  accompanied 
by  temporary  relief;  but  this  was  followed  by  an  increase  of 
swelling,  and  by  the  fever  assuming  the  hectic  form.  Dr. 
West,  Sir  J.  Paget,  and  Dr.  De  Mussy  were  all  consulted,  and 
when  I  first  saw  the  patient  her  sufferings  were  so  excessive 
that  the  examination  could  only  be  made  when  she  was  under 
the  influence  of  chloroform.  The  abdominal  swelling  was 
principally  confined  to  the  right  side,  and  extended  nearly  as 
high  as  the  false  ribs.  The  uterus  was  fixed,  pushed  forwards 
and  to  the  left,  and  there  was  distinct  pointing  in  the  vagina 
behind  and  to  the  right  of  the  uterus.  The  possibility  of  the 
existence  of  an  ovarian  cyst  which  had  rapidly  enlarged  and 
become  acutely  inflamed  was  carefully  considered,  but  the 
history  of  the  case  indicated  so  clearly  hematocele  followed 
by  pelvic  abscess,  which  was  pointing  towards  the  vagina,  that 
puncture  by  the  vagina  was  strongly  urged,  and  was  only 
deferred  owing  to  the  absence  of  a  member  of  the  family,  and 
in  the  hope  that  as  the  abscess  was  distinctly  pointing  it  would 
open  spontaneously.  A  few  hours  after  this  consultation, 
sudden  collapse  and  the  well-known  symptoms  of  perforating 
peritonitis  set  in,  followed  by  death  the  next  day.  In  another 
case  which  I  saw  with  Sir  James  Paget,  a  hematocele  passed 
below  Poupart's  ligament,  and  I  opened  it  in  the  thigh.  It 
was  completely  cured  by  drainage.  It  had  been  taken  for  psoas 
abscess  and  spinal  disease  ;  but  examination  by  the  vagina 
easily  led  to  a  correct  diagnosis. 

As  curiosities  of  surgical  experience,  but  not  arising  suffi- 
ciently often  to  call  for  more  than  passing  notice,  and  as 
morbid  changes  which    may  possibly  be  mistaken  for  ovarian 


OTHER    DISEASES    MISTAKEN    FOR    OVARIAN    CYSTS 


149 


disease,  may  be  enumerated  encephaloid  tumour  of  the  ilium, 
enchondroma  or  osseous  tumours  projecting  from  the  sacrum, 
angular  curvature  of  the  lumbar  vertebras,  enlargement  or 
malignant  disease  of  the  lumbar  glands,  or  dissecting  aneurism 
of  the  aorta.  I  know  of  one  case  where  a  tumour  in  the  pelvis 
was  punctured  by  the  vagina ;  the  patient  died  from  bleed- 
ing before  the  surgeon  left  the  room,  and  after  death  it  was 
found  that  an  aneurism  of  the  aorta  above  the  bifurcation  had 
dissected  downwards  behind  the  peritoneum,  and  formed  a 
considerable  tumour  in  the  hollow  of  the  sacrum.  I  have 
seen  three  cases  where  encephaloid  disease,  arising  in  the 
cancellated  bony  tissue  of  the  ilium,  had  not  only  projected 
backwards  and  towards  the  buttock,  but  so  far  inwards  and 
upwards  as  to  form  a  considerable  abdominal  tumour.  In  one 
of  these  cases  the  abdominal  tumour  transmitted  a  distinct 
pulsation  from  the  aorta ;  in  another  the  growth  itself  was 
pulsatile ;  in  the  third  the  rectum  was  completely  occluded  by 
the  growth.  The  other  states  above  enumerated  scarcely  need 
further  remark ;  a  little  attentive  consideration  of  the  history 
and  progress  of  the  cases  will  be  sufficient  to  distinguish  them 
from  any  form  of  ovarian  disease. 

Some  remarks  on  the  diagnosis  of  extra-uterine  pregnancy 
may  be  found  at  pages  122-23. 

The  woodcut  which  follows  may  serve  to  illustrate  a  com- 


bi  nation  of  retroverted  gravid  uterus  with  distended  bladder, 
which  might  possibly  become  the  cause  of  an  error  in  diagnosis 


150  MEDICAL   TREATMENT   PALLIATIVE 


CHAPTER    III 

THE   MEDICAL   TREATMENT   OF   OVARIAN   TUMOURS 

I  do  not  say  that  medical  treatment  is  of  very  little  use  in  cases 
of  ovarian  tumour,  simply  because  I  am  a  surgeon  and  can 
remove  the  disease.  But  on  looking  over  the  medical  litera- 
ture of  the  subject,  one  finds  the  keynote  of  this  chapter 
always  the  same — hopeless  impotence. 

The  sum  of  medical  doctrine  on  the  subject  amounts  to 
this  :  palliate  where  you  can ;  do  no  mischief  where  you  cannot. 
The  general  state  of  health  of  the  patient  is  obviously  the  first 
consideration ;  every  attention  is  to  be  paid  to  it.  All  matters 
of  diet,  hygiene,  tonics  for  the  body,  and  consolation  for  the 
mind  are  to  be  regulated  and  administered  under  the  convic- 
tion that  whatever  tends  to  support  the  strength  and  cheer  the 
spirits  of  the  patient  does  as  much  as  can  be  done  in  arresting 
the  progress  of  a  disease  which,  in  its  essentially  parasitic 
character,  flourishes  under  despondency  and  preys  upon  weak- 
ness. Though  all  these  cases  are  not  utterly  hopeless,  and 
some  few  may  spontaneously  come  to  a  standstill,  yet  when 
steady  progress  can  be  observed  from  time  to  time,  it  is  better 
at  once  to  disabuse  the  mind  of  vain  expectations,  to  seek 
temporary  relief  of  urgent  symptoms  by  rational  expedients, 
and  either  to  encourage  a  buoyant  anticipation  of  ultimate 
rescue  by  operation,  or  to  lead  the  patient  by  degrees  towards 
confiding  resignation  to  the  inevitable. 

The  local  miseries  which  we  have  to  alleviate  mostly  arise 
from  pressure  or  congestion.  The  due  action  of  the  bowels 
and  bladder  is  interfered  with,  the  veins  are  pressed  upon, 
and  oedematous  swelling  of  the  extremities  shows  itself,  the 
area  of  the  chest  is  encroached  upon  and  breathing  is  made 
difficult,  a  teasing  cough  supervenes,  or  the  heart  is  embarrassed 
and  the  brain  action  enfeebled.     Common  sense  will  suggest 


IN    OVARIAN    DISEASE  151 

the  fitting  choice  of  sedatives  or  stimulants,  aperients  or 
enemas,  the  use  of  the  catheter,  changes  of  position,  the  appli- 
cation of  bandages  or  mechanical  supports,  and  the  possibility 
of  relief  sometimes  to  be  obtained  by  manually  shifting  the 
position  of  the  tumour  when  it  is  low  down  or  impacted  in  the 
pelvis. 

Although  many  writers  have  insisted  on  the  supposed  fact 
that  vascular  excitement  and  congestion  aggravate  every  symp- 
tom, and  accordingly  enforce  the  utmost  possible  precaution 
against  sexual  excitement  and  marital  intercourse,  I  have  never 
actually  seen  more  than  would  lead  one  to  advise  that  concep- 
tion is  a  possibility  which  must  always  be  borne  in  mind.  It 
is  true  that  oftentimes  the  pregnancy  proceeds  to  its  end,  and 
labour  is  accomplished  without  much  more  than  ordinary  diffi- 
culty ;  yet  the  complication  is  a  cause  of  just  anxiety,  and  may 
even  give  rise  to  a  state  of  things  which  renders  the  question 
between  palliative  measures  and  removal  no  longer  one  of 
choice,  and  places  the  patient  under  the  obvious  disadvantages 
of  an  operation  more  than  otherwise  serious. 

But,  independently  of  the  troubles  incident  to  the  ordinary 
course  of  the  disease,  accidents  will  happen.  The  patient  may 
get  some  local  injury  from  a  blow  or  a  fall,  or  she  may  be 
chilled,  and,  as  usual,  the  weakest  part  suffers.  Inflammation 
is  set  up  in  the  tumour  or  in  the  peritoneal  covering,  and 
judicious  treatment  is  called  for.  Absolute  rest,  fomentations 
or  poultices,  and  opium,  with  or  without  mercury,  must  be 
used  so  as  to  avoid,  if  it  can  any  way  be  averted,  the  com- 
plication of  pus  formation  or  plastic  adhesions. 

The  verdict  of  Boinet  against  the  value  of  oxide  of  gold 
in  the  treatment  of  ovarian  cysts  will  apply  with  equal  truth 
to  the  proposals  made  in  this  country  to  cure  ovarian  cysts  by 
chlorate  of  potash.  Either  no  good  has  been  done,  or,  where 
real  benefit  has  followed  the  use  of  the  remedy,  no  doubt  there 
had  been  a  mistake  in  diagnosis.  So  with  the  supposed  value 
of  drastic  purgatives  and  hydragogues ;  if  used  when  the  dropsy 
is  really  ovarian  they  have  often  done  harm,  rarely  good. 
When  they  have  done  good,  fluid  has  been  free  in  the  peritoneal 
cavity  or  discharged  into  it.  Some  years  ago  I  met  with  a 
curious  illustration  of  this  statement.  I  was  asked  to  see  a 
young  lady  in  consultation  with  Dr.  Headlam  Greenhow,  who 


152      EXCEPTIONAL  CASE  OF  CURE  BY  PURGATIVES 

had  ascertained  that  she  was  the  subject  of  a  large  single 
ovarian  cyst,  and  had  recommended  tapping,  as  the  distension 
was  rapidly  becoming  greater  and  more  distressing.  The  late 
Dr.  Marsden  had  also  seen  the  patient.  He  believed  the 
disease  to  be  ascites,  said  that  tapping  was  unnecessary,  and 
that  he  could  cure  the  patient  by  calomel  and  elaterium.  After 
a  careful  examination  of  the  patient,  I  satisfied  myself  that 
Dr.  Grreenhow's  diagnosis  was  correct.  The  fluid  was  distinctly 
confined  in  front  of  the  intestines  by  a  cyst,  and  there  were 
none  of  the  variations  of  sound  on  percussion  after  alterations 
in  the  position  of  the  patient,  which  are  so  characteristic  in 
ascites.  Indeed,  the  case  would  have  been  a  typical  one  for 
teaching  to  a  class  the  physical  signs  of  a  large  single  cyst.  I 
quite  agreed  with  Dr.  Grreenhow  that  tapping  was  clearly  indi- 
cated, and  that  drastic  purgatives  could  only  be  useful  if  the 
cyst  should  burst.  As  increase  in  size  had  been  very  rapid, 
and  the  cyst  was  evidently  thin,  I  thought  spontaneous  rup- 
ture would  very  likely  take  place  if  tapping  were  not  soon 
resorted  to,  and  that  rupture  would  be  still  more  likely  if 
violent  purgatives  were  given.  The  danger  of  tapping  seemed 
to  me  to  be  very  much  less  than  the  danger  either  of  spon- 
taneous rupture,  or  of  rupture  accelerated  by  purging.  This 
was  fully  explained  to  the  friends,  but  they  chose  to  submit 
the  patient  to  the  medical  rather  than  to  the  surgical  treatment 
It  is  only  fair  to  the  memory  of  Dr.  Marsden  to  say  that  his 
treatment  was  followed  by  complete  success.  The  patient  was 
dangerously  ill  for  a  time,  and  I  have  no  doubt  whatever  that 
a  thin  cyst  did  give  way,  its  contents  escaped  into  the  peri- 
toneal cavity,  were  absorbed,  and  were  carried  off  by  the  watery 
motions  excited  by  the  calomel  and  elaterium.  For  one  such 
rare  success  as  this  I  feel  sure,  however,  that  a  repetition  of 
similar  treatment  would  be  followed  by  many  failures,  by  much 
useless  suffering,  and  by  great  danger.  I  only  record  the  case 
here  as  a  warning  to  those  who  would  unhesitatingly  condemn 
such  attempts  as  necessarily  and  invariably  useless,  and  to  show 
the  necessity  of  explaining  the  possibility  of  their  occasional 
success  under  rare  and  exceptional  conditions. 

Whenever  an  ovarian  cyst  or  tumour  has  attained  so  large  a 
size  that  the  comfort  and  general  health  of  the  patient  are 
seriously   interfered   with,   it   may  be   taken  as   certain   that 


QUESTION    OF   TIME   FOR   SURGICAL    INTERFERENCE  153 

ordinary  medical  or  palliative  treatment  will  be  of  little  avail. 
Any  specific  medical  treatment  by  iodine,  or  bromine,  or  mer- 
cury, or  gold,  or  arsenic,  or  lime,  or  potash,  used  with  the  hope 
of  modifying  the  nutrition  or  checking  the  growth  of  such 
tumours,  must  be  as  useless  as  any  diuretics  or  other  medi- 
cines expected  to  lead  to  absorption  of  the  contents  of  the 
cyst ;  and  it  would  be  well  if  the  rule  were  adopted  to  prohibit 
any  medical  treatment  which  could  possibly  injure  the  general 
health  of  the  patient,  or  place  her  in  a  less  favourable  condition 
than  she  otherwise  would  be  for  such  surgical  treatment  as  may 
ultimately  be  called  for. 

The  question  when  surgical  aid  really  is  required,  or  how 
long  a  patient  should  be  left  to  ordinary  medical  care,  undis- 
turbed by  any  surgical  treatment,  is  one  which  is  daily  occur- 
ring in  practice,  and  the  answer  should  be  framed  upon  some 
such  common-sense  rules  as  the  following :   so   long   as    the 
patient  does  not  suffer  much  pain,  is  not  annoyed  by  her  size 
and  appearance,  has  no  great  difficulty  in  locomotion,  does  not 
suffer  from   injurious   pressure    on  the  organs    of  the   chest, 
abdomen,   or   pelvis ;  and   so   long   as   the  heart  and   lungs, 
digestive  organs,  kidneys,  bladder,  and  rectum  perform  their 
functions  tolerably  well,  the  idea  of  a  surgical  operation  should 
seldom  be  entertained.     And  if  we  look  only  at  the  urgency  of 
the  present  circumstances,  nothing  need  be  done.     Life  is  not 
immediately  threatened,  and  by  watching  the  advancing  symp- 
toms the  moment  for  action  can  almost  always  be  determined. 
But  with  the  experience  of  the  nine  years  which  have  elapsed 
since  the  publication  of  my  edition  of  1872, 1  have  become  more 
and  more  disposed  to  advise  the  removal  of  an  ovarian  tumour 
as  soon  as  its  nature  and  connections  can  be  clearly  ascertained, 
and  it  is  beginning  in  any  way  physically  or  mentally  to  do 
harm,  since  the  risk  of  the  operation  under  such  circumstances 
is  certainly  less,  and  the  possible  evils  of  delay  are  eluded. 
AVhere,  however,  while  the  development  continues,  the  symp- 
toms follow  their  usual  course,  and  the  distress  of  the  patient 
forces  her  to  demand  some  kind  of  relief,  there  is  either  reluct- 
ance or  refusal  to  face  the  liabilities  of  excision,  or  family  con- 
siderations impose  the  necessity  of  delay,  the  size,  nature,  and 
connections  of  the  tumour  must  guide  us  in  the  selection  of  one 
or  other  of  the  minor  methods  of  palliative  surgical  treatment, 


154  SURGICAL   MEASURES 

which,  though  they  seldom  lead  to  a  cure,  have  the  advantage 
of  enabling  us  to  alleviate  the  most  distressing  symptoms,  and 
to  wait  for  an  opportunity  to  try  some  of  the  greater  expedients 
which  have  been  from  time  to  time  adopted  for  the  obliteration 
of  these  cysts,  or  to  carry  out  the  last  resource  of  ovariotomy. 

These  palliative  measures,  or  what  may  be  called  minor 
methods  or  substitutes  for  ovariotomy,  may  be  thus  enumer- 
ated : — 

1.  Simple  tapping  through  the  abdominal  walls. 

2.  Simple  tapping  through  the  vagina. 

3.  Simple  tapping  through  the  rectum. 

4.  Tapping  followed  by  pressure. 

5.  Tapping  and  the  formation  of  a  permanent  intra-peri- 

toneal  opening  in  the  cyst  wall. 

6.  Tapping  and  drainage,  or  the  formation  of  a  permanent 

opening  through  the  abdominal  wall,  the  vagina,  or  the 
rectum. 

7.  Incision. 

8.  Tapping  followed  by  injection  of  iodine. 


GENERAL   REMARKS   ON   TAPPING  155 


CHAPTEE  IV 

ON  THE   PALLIATIVE   AND   MINOR  SURGICAL   TREATMENT   OF 
OVARIAN    TUMOURS 

TAPPING. 

As  experience  has  increased  and  the  mortality  after  ovario- 
tomy has  diminished,  professional  opinion  has  been  unsettled  as 
to  the  use  or  propriety  of  tapping  ovarian  cysts.  Some  writers 
have  gone  so  far  as  to  assert  that  it  is  an  operation  which  ought 
to  be  completely  abandoned.  Stilling,  for  example,  in  his  work 
on  the  'Extra-Peritoneal  Method  of  Ovariotomy,'  says,  p.  161, 
that  '  No  surgeon  should  ever  puncture  an  ovarian  cyst.  Tap- 
ping is  a  crimed  He  adds,  '  Never  tap.  Ovariotomy  becomes 
more  difficult  the  oftener  a  patient  has  been  tapped  before  it, 
and  the  patient  is  made  worse  by  every  tapping.' 

Few  surgeons  here  would  assent  to  this,  but  there  are 
many  who  object  to  tapping  on  two  grounds — first,  that  it  is 
dangerous  in  itself,  and  can  only  be  of  temporary  utility ;  and 
secondly,  that  it  is  likely  to  be  followed  by  adhesions  or  other 
conditions  which  add  greatly  to  the  danger  of  subsequent 
ovariotomy. 

In  considering  the  objection  to  tapping  on  the  ground  of  its 
danger,  as  compared  with  the  danger  of  ovariotomy,  some 
writers  appear  to  me  to  have  fallen  into  a  great  error.  They 
take  a  certain  number  of  cases  of  ovarian  disease,  and  say  that 
so  many  patients  died  after  one  tapping,  so  many  after  five, 
six,  or  ten,  and  conclude  that  tapping  is  a  very  fatal  operation. 
I  have  heard  it  gravely  asserted  that  it  is  a  more  fatal  opera- 
tion than  ovariotomy,  because  after  ovariotomy,  nine  tenths 
of  the  patients  recover,  while  after  tapping,  sooner  or  later, 
they  all  die.  But  the  very  important  distinction  is  overlooked 
between  an  operation  which  either  cures  or  kills,  and  one  which 


156  TAPPING   THKOUGH 

only  fails  to  save  life,  or  kills  only  under  most  exceptional 
circumstances. 

It  is  seldom  that  a  surgeon  is  called  upon  to  perform 
ovariotomy  in  order  to  save  a  patient  from  imminent  death. 
But  this  does  occasionally  happen.  Dr.  Wiltshire  and  Dr. 
Watson  have  published  a  case  where  a  woman,  who  was  dying 
from  bleeding  into  an  ovarian  cyst,  was  saved  by  immediate 
ovariotomy.  I  have  been  sent  for  twice  to  operate  under  similar 
circumstances,  but  both  patients  were  dead  before  I  arrived. 
In  both  large  veins  had  burst,  and  some  pounds  of  blood  were 
found  inside  ovarian  cysts.  If,  in  any  of  these  cases,  the  death 
of  the  patient  had  followed  ovariotomy,  it  could  hardly  be  said 
that  this  operation  had  killed  the  patient ;  it  had  only  failed 
to  save  life.  So,  if  a  patient  be  near  death,  poisoned  by  an 
ovarian  tumour  in  a  state  of  gangrene  from  twist  in  the 
pedicle,  or  by  the  fetid  contents  of  a  suppurating  cyst,  ova- 
riotomy, if  performed  unsuccessfully,  can  only  be  said  to  fail 
in  saving  life — it  cannot  be  said  to  kill.  Yet  I  have  operated 
successfully  under  such  desperate  circumstances ;  and  several 
times  when  rupture  of  a  cyst  into  the  peritoneal  cavity  had 
been  followed  by  diffuse  peritonitis.  In  any  such  case, 
ovariotomy  must  be  identified  with  trephining,  tracheotomy, 
herniotomy,  or  the  ligature  of  some  large  artery  in  a  case  of 
wound  or  burst  aneurism,  or  primary  amputation  of  a  limb  in 
compound  fracture.  It  is  not  the  operation  which  is  the  cause 
of  death,  but  the  disease  or  accident  from  the  effects  of  which 
the  patient  is  not  saved  by  the  operation. 

But  such  cases  as  those  just  alluded  to  must  be  very  rare 
exceptions  to  the  large  majority  in  which  ovariotomy  becomes 
the  subject  of  consultation.  There  is  generally  as  much  time 
for  discussion  as  in  the  parallel  case  of  lithotomy  in  the  male 
adult.  And  in  both  cases  the  responsibility  of  operating  with 
the  full  knowledge  that,  if  the  patient  be  not  saved  by  the 
operation,  he  or  she  is  killed  by  it,  must  be  fairly  faced.  It  is 
true  that  death  would  almost  always  be  caused  by  the  stone 
or  the  ovarian  tumour,  but  it  might  be  at  a  distant  period,  and 
if  death  follow  the  operation  in  a  few  days  the  operation  must 
then  be  regarded  as  its  immediate  cause. 

Tapping  stands  on  a  totally  different  ground.  As  a  rule, 
when  a  patient  dies  after  tapping,  it  is  not  that  tapping  has 


THE   ABDOMINAL   WALL  157 

hastened  her  death,  but  simply  has  not  succeeded  in  saving  her 
life.  Her  life  may  have  been  prolonged  by  repeated  tappings, 
but  at  last  she  dies  worn  out  by  the  disease. 

Tapping  may  be  practised — first,  through  the  abdominal 
wall ;  secondly,  through  the  vagina ;  and,  thirdly,  through  the 
rectum.  Whichever  of  these  methods  may  be  selected,  it  may 
be  trusted  to  alone,  or  it  may  be  followed  by  pressure,  or  by 
drainage,  or  by  the  formation  of  a  permanent  opening,  either 
in  the  cyst  wall  only,  with  the  object  of  establishing  a  constant 
communication  with  the  peritoneal  cavity,  or  through  the  ab- 
dominal wall,  vagina,  or  rectum.  In  the  one  case  the  fluid 
passes  into  the  peritoneal  cavity  and  is  absorbed,  no  external 
opening  being  left ;  in  the  other  a  fistulous  external  opening 
is  kept  up  until  the  cyst  ceases  to  pour  out  fluid  and  becomes 
obliterated.  In  any  of  these  cases  the  processes  may  be  assisted 
by  pressure ;  and  in  some  tapping  may  be  followed  by  the  injec- 
tion of  iodine. 


TAPPING   THROUGH   THE   ABDOMINAL   WALL 

was  formerly  practised  with  the  patient  sitting  in  a  chair,  a 
pail  between  her  legs,  an  assistant  on  either  side  of  her,  keeping 
a  sheet,  or  long  towels,  so  tightened  round  the  abdomen  by 
pulling  at  the  ends,  that  the  escape  of  the  fluid  was  supposed 
to  be  assisted,  and  the  fainting  of  the  patient  prevented.  A 
hole  in  the  sheet,  or  a  space  between  two  towels,  left  room 
for  the  passage  of  the  trocar.  The  operator,  standing  in  front 
of  the  patient,  used  the  trocar  like  a  dagger,  stabbing  with  con- 
siderable force.  A  good  deal  of  discussion  arose  at  one  time  as 
to  the  propriety  of  dividing  the  skin  and  fascia  with  a  lancet 
before  using  the  trocar.  Some  thought  it  unnecessarily  pro- 
longed the  operation,  others  thought  it  spared  the  patient  the 
shock  and  pain  of  a  forcible  stab.  Any  way  the  operation  was 
a  very  distressing  one.  The  fainting  of  the  patient  was  by  no 
means  uncommon ;  she  suffered  from  exposure  and  shock,  her 
clothing  was  often  wetted  by  the  fluid,  and  she  was  taken  back 
to  bed  frightened,  wet,  cold,  faint,  and  exhausted.  No  doubt 
some  of  the  dangers  of  tapping  depended  upon  the  clumsy 
method  of  proceeding.  It  is  difficult  to  understand  otherwise 
thai   the  mortality  after  tapping  could  possibly  have  been  as 


158  PRECAUTIONS   TO    BE    USED 

high  as  many  writers  have  estimated  it.  Simpson's  calculation 
was  that  the  mortality  after  first  tappings  was  not  less  than  one 
in  six.  Under  the  present  simplified  mode  of  tapping,  I  very 
much  doubt  if  it  is  as  much  as  one  in  sixty.  I  believe  it  is 
considerably  less  than  this  in  my  own  experience.  I  have 
removed  115  pints  of  fluid  from  a  patient  at  one  tapping,  and 
121  from  another,  without  the  slightest  sign  of  faintness,  with- 
out wetting  either  the  linen  of  the  patient  or  the  bed  clothes, 
and  without  disturbing  her  position  in  the  bed.  I  have  often 
had  occasion  to  remove  30,  40,  or  50  pints  of  fluid  from  patients 
as  they  lay  on  the  side  in  bed,  and  they  are  only  conscious  of 
the  relief  afforded  by  the  removal  of  pressure.  It  is  quite  un- 
necessary to  take  the  patient  out  of  bed;  if  she  has  been 
moving  about  she  should  go  to  bed,  and  should  lie  on  one  side 
near  the  edge  of  the  bed,  so  that  the  abdomen  projects  over 
the  edge.  As  a  rule,  the  linea  alba  is  the  preferable  site  for 
puncture,  but  any  hard  portions  of  the  tumour  should  be 
avoided,  and  the  most  elastic  or  distinctly  fluctuating  points  of 
the  tumour  selected.  Before  puncturing,  great  care  should  be 
taken  by  palpation  and  percussion  to  ascertain  that  no  intestine 
is  lying,  or  adhering,  between  the  cyst  and  the  abdominal  wall, 
at  the  point  selected  for  tapping ;  and  any  visible  superficial 
veins  should  be  avoided.  It  is  certainly  advantageous  to  punc- 
ture the  skin  with  a  lancet  before  using  the  trocar,  and  if  the 
patient  is  very  sensitive  to  pain  the  seat  of  puncture  may  be 
frozen  by  ether  spray.  And  every  now  and  then  with  a  very 
nervous  subject,. or  where  the  excessive  accumulation  of  fat  on 
the  abdomen  gives  a  formidable  look  to  the  proceedings,  and 
may  perhaps  occasion  some  little  difficulty  in  driving  the  canula 
to  its  destination,  it  may  be  as  well  to  administer  a  slight 
amount  of  some  anaesthetic  so  as  to  calm  the  timidity,  or  give 
the  operator  the  opportunity  of  doing  what  he  has  to  do  with 
greater  facility. 

The  condition  of  the  cyst  wall  may  also  be  the  cause  of 
embarrassment  or  danger  in  tapping.  I  have  many  times 
observed  it  so  far  gone  in  degenerative  changes  as  to  make  it 
absolutely  friable ;  and  though  it  has  been  kept  entire  by  the 
equable  support  of  the  surrounding  parts,  any  essays  to  puncture 
with  a  trocar  must  have  crushed  it  and  caused  the  discharge  of 
the  contents.     In  at  least  three  operations  where  I  came  upon 


IN   TAPPING  159 

fluid  free  in  the  peritoneum,  on  examining  the  cyst,  the  hole  made 
in  a  previous  tapping  was  quite  open,  a  piece  of  inelastic  matter 
having  been  forced  away  so  that  there  was  no  possibility  of  closing 
There  have  been,  too,  some  examples  among  my  cysts  of  bony 
deposit  in  the  tissue  sufficiently  hard  to  turn  the  point  of  a 
trocar  if  it  happen  to  impinge  upon  the  spot,  and  Dr.  Eitchie 
reports  of  one  of  my  tumours,  No.  96,  a  partial  thickness  of  two 
inches,  enough  to  arrest  any  ordinary  operator  under  the  im- 
pression that  he  had  come  into  contact  with  a  solid  fibroid.  In 
other  multilocular  cysts  one  compartment  may  have  walls  of 
almost  impenetrable  solidity,  and  an  adjoining  one  of  not  more 
than  a  line  in  thickness,  so  that  a  first  attempt  to  draw  off  fluid 
may  be  an  utter  failure  and  lead  to  an  erroneous  conclusion, 
while  the  next,  from  shifting  of  the  position  of  the  mass  or 
change  of  point  of  puncture,  may  fall  upon  a  thin  loculus,  give 
vent  to  the  contents,  and  alter  the  diagnosis  completely. 

The  trocar  has  been  greatly  improved  of  late  years.  The 
old  instrument  was  so  short  that,  if  the  abdominal  wall  was 
thick,  the  trocar  never  reached  the  cyst,  or  it  may  just  have 
punctured  the  cyst,  and  the  canula  was  too  short  to  follow  it. 
In  the  first  case  no  good,  but  no  harm,  was  done ;  in  the  second 
the  results  were  dangerous  or  fatal.  The  punctured  cyst  poured 
out  its  contents  into  the  peritoneal  cavity,  and  dangerous 
symptoms  or  death  followed,  the  danger  arising  not  necessarily 
from  the  tapping,  but  from  the  bad  way  in  which  it  was  done. 

Great  difference  of  opinion  has  been  expressed  as  to  the 
danger  or  harmlessness  of  admitting  air  into  an  ovarian  cyst 
while  the  fluid  is  escaping.  Some  writers  have  argued  that  it 
can  do  no  harm.  My  own  opinion,  founded  upon  the  few  cases 
where  I  have  been  quite  sure  that  air  has  entered,  is  very 
decidedly  in  accordance  with  those  who  assert  it  to  be  frequently 
followed  by  cyst  inflammation,  and  by  the  fever  which  accom- 
panies it,  and  by  decomposition  of  the  fluid  which  remains  in  the 
cyst,  or  is  secreted  soon  after  the  tapping.  I  therefore  regard  the 
improvement  in  the  trocar  which  provides  against  the  entrance 
of  air  into  the  cyst  during  the  escape  of  fluid,  as  an  important 
element  in  the  diminution  of  the  mortality  after  tapping.  We 
are  indebted  to  Mr.  Charles  Thompson,  of  Westerham,  for 
introducing  the  simplest  and  most  effectual  instrument  by 
which  this  object  has  been  attained.    This  was  described  in  the 


160 


MODE   OF    USING 


'Medical  Times  and  Gazette,'  March  27,  1858,  as  a  'new trocar 
for  paracentesis  thoracis.'  In  his  own  words,  '  it  consists  of  a 
cylindrical  silver  canula  about  four  inches  long,  into  which  opens 
at  near  its  middle  a  short  silver  conducting  tube  of  the  same 
calibre,  to  which  a  piece  of  india-rubber  tubing  about  a  foot 
long  is  attached  by  a  screw.      In  this  canula  plays  a  solid  steel 


piston,  with  a  trocar  point,  its  body  being  of  such  length  that, 
when  fully  pushed  forward,  as  in  the  above  figure,  its  point 
protrudes  sufficiently  from  the  canula,  and  its  other  extremity 
seals  the  entrance  of  the  conducting  tube  ;  and,  when  fully 
withdrawn,  as  in  this  figure — 


=^ 


it  retires  so  far  as  to  open  the  conducting  tube.  This  piston 
must  fit  the  canula  so  perfectly  as  to  be  air-tight  when  greased. 
The  little  cap  of  the  canula  unscrews  to  admit  of  the  removal 
of  the  piston  for  greasing  or  cleaning.  The  outer  half  of  the 
canula  is  mounted  in  a  solid  wooden  handle  to  give  a  firm  grasp 
of  the  instrument. 

6  The  mode  of  using  it  is  as  follows  :  Having  well  greased 
the  piston,  draw  it  back,  as  in  the  second  figure,  and,  placing 
the  end  of  the  elastic  tube  into  a  basin  of  water,  withdraw  the 
air  from  it  by  suction  at  the  end  of  the  canula,  and  when  the 
water  reaches  the  lips  push  forward  the  piston.  The  elastic 
tube  is  now  filled  with  water,  which  cannot  escape,  and  the 
instrument  is  ready  for  use.  When  it  is  plunged  into  the 
chest,  pull  back  the  piston  so  as  to  open  the  conducting  tube. 
When  the  fluid  follows,  and  directly  it  meets  the  water  in  the 
tube,  a  syphon  is  formed.  The  end  of  the  tube  should  be  kept 
under  fluid  during  the  operation.  If  it  is  required  to  stop  the 
flow  either  during  a  fit  of  coughing  or  to  change  the  receiving 
vessel,  it  can  be  done  instantaneously  by  just  advancing  the 
piston  sufficiently  to  cover  the  conducting  tube.' 


THE    SYPHON    TROCAR  161 

As  soon  as  I  read  this  description  of  the  new  trocar,  I 
saw  how  useful  it  would  be,  both  in  tapping  ovarian  cysts  and 
in  ovariotomy,  and  I  had  instruments  made  with  canulas 
of  different  lengths  and  calibre,  suitable  for  both  purposes, 
and  continued  to  use  them  for  some  months,  and  found  that 
great  advantages  were  gained  by  the  use  of  the  instrument. 
Admission  of  air  was  prevented^  the  syphon  action  assisted 
in  keeping  up  a  continuous  flow  of  fluid,  while  the  escape 
could  be  stopped  at  any  desirable  moment.  If  the  tube  or 
canula  became  blocked  it  was  easily  cleared.  The  fluid  was 
conveyed  into  the  receiving  vessel,  while  the  patient  was  kept 
perfectly  dry,  not  alarmed  by  the  splashing  of  the  fluid,  and 
not  disturbed  by  the  changing  of  the  basins,  which  was  so 
troublesome  when  the  old  instrument  was  used.  To  some  a 
practical  improvement  of  this  kind  may  appear  of  small  value, 
but  any  one  who  does  much  real  work  at  the  bedside  will,  I 
think,  agree  with  me  in  the  opinion  that  Mr.  Thompson,  by 
this  simple  and  ingenious  contrivance,  has  proved  himself  to  be 
worthy  of  his  hereditary  position,  and  of  the  estimation  in  which 
his  family  have  been  held  for  generations  in  the  county  of  Kent. 

While  still  desirous  to  carry  on  the  principle  of  the  syphon, 
as    adapted   to   the  trocar,  I    became    anxious    to   avoid   the 
momentary  delay,  between  the  introduction  of  the  trocar  and 
the  escape  of  the  fluid,  while  the  piston  was  being  withdrawn. 
I  was  led  to  this  by  observing  that,  when  using  the  large-sized 
instrument  in  ovariotomy,  there  was  sometimes  a  rush  of  fluid 
between   the   cyst  and  the   outside  of  the  canula  before  the 
piston  could  be  withdrawn,  and  it  was  evident  that  the  same 
thing  might  occur  during  ordinary  tapping.     I  was  therefore 
anxious  to  make    the  piston  hollow,  but,  after  two   or   three 
trials,  it  occurred  to  me  that  something  like  a  steel  pen  sliding1 
in  the  pencil-cases  in  ordinary  use  might  be  a  more  convenient 
mode  of  effecting  the  object  in  view.     I  first  carried  out  this 
idea  in  an  instrument  of  the  size  for  ovariotomy,  adding,  to  the 
ontside  of  the  canula,  grooves   upon  which  the  cyst  could  be 
tied  as  it  became    lax.     This  instrument  was  described  in  a 
paper  read  before  the  Koyal  Medical  and  Ohirurgical  Society. 
Modifications  which  I  have  since  made  in  this  instrument  will 
be  described  in  the  chapter  on  Ovariotomy.     When  the  instru- 
ment is  made  of  the   size    for  simple  tapping,  the    canula  is 

M 


162 


DESCRIPTION   AND    USE    OF   TROCAR 


perfectly  smooth.  A  lancet  puncture  is  made  through  the 
skin,  and  the  instrument  is  then  easily  thrust  into  the  cyst. 
Fluid  escapes  immediately,  and  the  point  is  at  once  withdrawn 
to  prevent  injury  to  the  cyst  as  it  contracts.  It  is  important 
that  the  edges  of  the  canula  should  not  be  thin,  but  perfectly 
smooth  and  well  rounded  off.  There  would  otherwise  be 
danger  of  injury  to  large  veins  on  the  inner  surface  of  the 
cyst ;  and  the  maker  should  be  careful,  in  sharpening  the 
cutting  end  of  the  hollow  trocar,  to  leave  one  half  of  the  lips 
quite  blunt.  If  sharpened  all  round  it  would  act  as  a  punch, 
and  cut  a  circular  hole  in  the  skin.  I  have  seen  a  tube 
blocked  in  this  way,  and  I  have  more  than  once  seen  a  round 
piece  of  skin  floating  in  the  fluid,  or  so  nearly  detached  after 


the  canula  was  withdrawn  that  it  was  better  to  cut  it  away. 
If  the  instrument  is  properly  finished,  only  a  semilunar  cut 
is  made  in  the  skin  and  cyst,  which  closes  much  more  readily 
than  the  triangular  puncture  made  by  the  old  trocar. 

Instead  of  the  india-rubber  tube,  it  is  quite  easy  to  fix  to 
the  end  of  the  canula  an  ordinary  india-rubber  enema  syringe, 
by  which  more  powerful  exhausting  suction  can  be  brought  to 
bear  upon  the  contents  of  the  cyst  than  can  be  obt  ined  by  the 
syphon  tube ;  and  if  it  be  desirable  to  wash  out  the  cyst,  or  to 
inject  iodine  or  any  other  antiseptic  into  it,  this  can  be  readily 
done  by  reversing  the  syringe  without  removing  the  canula. 

When  using  this  syphon  trocar  it  is  not  necessary  to  fill  the 
tube  with  water,  as  Mr.  Thompson  directs,  if  care  be  taken  so 
to  introduce  the  instrument  that  the  point  passes  into  the 
fluid  at  a  lower  level  than   the  commencement  of  the  tube, 


BLEEDING    AFTER    TAPPING  1G3 

as  shown  in  the  sketch  on  the  previous  page.  Air  will  not  descend 
except  under  strong  suction,  or  into  a  vacuum,  and  there  is  no 
fear  of  air  passing  up  the  tube  and  down  the  canula  into  the 
cyst.  The  instant  the  canula  enters  the  cyst,  fluid  rushes  into 
it,  pressing  the  air  before  it,  and  if  the  tube  be  properly  mounted 
so  that  it  does  not  bend  or  narrow  the  canal,  the  tube,  which 
should  be  about  three  feet  long5  at  once  becomes  the  long  arm 
of  a  syphon.  The  suction  power  of  this  long  column  of  fluid  is 
so  great  that  the  air  can  be  heard  to  be  drawn  bubbling  into 
the  tube,  even  through  the  well-fitting  bayonet  joint  provided 
for  the  withdrawal  of  the  point  of  the  instrument.  It  is 
better  to  keep  the  end  of  the  tube  under  the  fluid  when  the 
cyst  is  nearly  empty$  to  avoid  any  accidental  drawing  inwards 
of  air  as  a  patient  makes  some  deep  inspiration  or  expiration, 
leading  to  a  kind  of  vacuum  within  the  abdomen ;  and  in 
withdrawing  the  instrument  it  is  always  well  to  press  the 
abdominal  wall  close  down  upon  the  cyst,  and  with  the  finger  and 
thumb  of  the  other  hand  so  to  hold  the  abdominal  walls  together 
behind  the  escaping  canula  as  to  prevent  any  entrance  of  air. 

Instead  of  the  syphon^trocar  some  surgeons  have  used 
aspirators  of  different  sizes  and  modifications.  But  they  are 
all  open  to  the  objection  that,  as  the  cyst  becomes  empty  its 
flaccid  walls  are  sucked  into  the  end  of  the  canula  and  stop  the 
flow  of  fluid* 

Should  any  bleeding  follow  the  removal  of  the  instrument 
and  not  be  stopped  by  a  little  pressure,  a  harelip  pin  may 
be  passed  completely  across  the  opening,  deeply  enough 
beneath  the  skin  to  compress  any  injured  vessel.  Two  or 
three  turns  of  silk  twisted  round  the  pin  make  sufficient 
pressure  to  stop  any  bleeding.  It  will  not  do  simply  to 
bring  the  edges  of  the  skin  together  with  a  pin ;  this  might 
only  conceal  dangerous  internal  bleeding.  In  some  cases  in- 
ternal hasmorrhage,  even  fatal,  has  followed  the  puncture,  and 
this  may  be  explained  either  by  the  opening  of  varicose  vessels 
in  the  cyst  wall,  where  they  sometimes  attain  enormous  de- 
velopment, or  by  the  presence  of  such  enlarged  veins  in  the 
omentum  as  were  found  in  the  examination  of  the  woman 
operated  on  as  my  731st  case,  where  the  size  was  such  as  to 
have  made  the  suppression  of  bleeding  impossible  without  im- 
mediate gastrotomy.     One  of  my  neighbours  lost  a  case  within 

M   2 


164  SUCCESSFUL   CASES   OF   SIMPLE   TAPPING 

a  few  hours  after  tapping;  upwards  of  five  pints  of  blood, 
which  had  escaped  from  a  varicose  vein,  having  been  found 
in  the  peritoneal  cavity.  The  vein  ran  directly  in  front  of 
the  peritoneum,  immediately  beneath  the  linea  alba,  from 
the  umbilicus  towards  the  liver.  A  pin  through  the  whole 
thickness  of  the  abdominal  wall  would  have  compressed  this 
vessel. 

Whenever  it  is  doubtful  if  a  cyst  has  been  completely 
emptied,  or  there  is  some  escape  of  fluid  after  the  removal  of  the 
trocar,  the  comfort  of  the  patient  is  greatly  increased  by  closing 
the  opening  with  a  harelip  pin  and  twisted  suture,  but  the  pin 
need  not  be  passed  so  deeply  as  in  case  of  bleeding.  I  was  led  to 
adopt  this  practice  from  the  remark  made  to  me  by  Mr.  Csesar 
Hawkins  upon  a  case  where  oozing  after  tapping  was  going  on. ' 
He  said,  '  When  they  ooze  they  always  die,'  so  I  determined 
that  they  should  not  ooze  unless  I  wished  to  drain.  In  ordinary 
cases  a  pin  is  not  necessary,  a  small  pad  of  lint  and  a  strip  of 
adhesive  plaster  being  quite  sufficient  to  cover  the  opening,  and 
the  abdomen  should  be  supported  by  an  ordinary  binder. 

In  order  to  prove  that  simple  tapping  through  the  abdominal 
wall  is  occasionally  followed  by  a  radical  cure,  the  following  cases 
are  important  : — 

In  July  1863  an  unmarried  domestic  servant,  30  years 
of  age,  came  from  Liverpool  to  the  Samaritan  Hospital.  The 
abdomen  was  so  distended  by  a  unilocular  cyst  that  the  ensi- 
form  cartilage  was  pushed  forwards.  I  decided  to  tap  this 
cyst,  and  if  I  found  the  contents  were  limpid  to  do  no  more, 
but,  if  viscid  fluid  escaped  or  secondary  cysts  were  found,  to 
perform  ovariotomy  at  once.  She  was  only  tapped,  and  soon 
after  returned  to  Liverpool  able  to  take  another  situation,  and 
was  very  well  for  about  three  years  after  the  tapping.  The 
lady  who  sent  her  afterwards  wrote  to  me  '  that  she  had  died 
in  Manchester,  I  cannot  remember  from  what  complaint,  but 
nothing  connected  with  the  disease.' 

In  April  1865  an  unmarried  lady,  20  years  of  age,  was 
sent  to  me  by  Dr.  Miller,  of  Southsea.  The  whole  abdomen 
was  distended  by  a  single  cyst,  which  had  been  forming  for 
about  eighteen  months.  The  lungs  were  beginning  to  suffer 
from  pressure,  and  I  advised  immediate  tapping,  stating  that 
the  case  might  prove  to  be  one  of  the  exceptional  instances  in 


SUCCESSFUL   CASES    OF   SIMPLE    TAPPING  165 

which  tapping  not  only  relieves  but  cures.  I  removed  fourteen 
pints  of  limpid  fluid  with  a  slightly  greenish  tint.  About 
four  ounces  were  preserved  in  a  bottle  for  examination.  On 
removing  the  stopper  bubbles  of  carbonic  acid  arose  as  from 
Seltzer  water.  The  reaction  was  strongly  alkaline.  On  boiling 
a  small  quantity  in  a  test  tube,  no  change  was  perceptible 
until  after  the  addition  of  nitric  acid,  when  an  abundant  white 
precipitate  appeared,  and  brisk  effervescence  took  place.  The 
precipitate  assumed  a  faint  greenish  tint,  and  the  supernatant 
fluid  was  absolutely  colourless.  Nothing  could  be  discovered 
in  it  by  microscopic  examination.  Probably  the  chief  alkali 
present  was  carbonate  of  soda,  for  when  the  fluid  was  added 
to  spirit  it  burned  with  a  very  yellow  flame.  The  patient 
returned  to  the  country  nine  days  after  the  tapping,  and 
remained  well  for  about  six  months.  Then  Dr.  Miller  informed 
me  that,  upon  the  termination  of  one  of  her  menstrual  periods, 
symptoms  of  peritonitis  showed  themselves,  but  yielded  in 
about  twenty  hours  to  calomel  and  opium.  With  this  ex- 
ception she  has  remained  perfectly  well,  and  without  any  sign 
of  refilling  of  the  cyst,  since  the  tapping.  I  heard  of  her  in 
1872  as  quite  well. 

In  July  1865  I  saw  an  unmarried  lady,  29  years  of 
age,  with  Mr.  Fox,  of  Weymouth  ;  made  the  diagnosis  of  a 
non-adherent  single  cyst,  advised  one  tapping,  and  removed 
thirty-two  pints  of  fluid,  as  clear  as  distilled  water,  on  July  20, 
1865.  Immediate  relief  followed  the  tapping,  and  in  February 
1866  Mr.  Fox  told  me  that  there  had  been  no  refilling,  and 
that  she  had  remained  remarkably  well  and  active.  The  history 
of  this  case,  both  before  and  after  the  tapping,  is  curious.  In 
June  1860,  although  she  was  very  large,  she  was  dancing,  gave 
a  sudden  scream,  became  faint,  and  collapsed.  Mr.  Fox  gave 
stimulants  freely.  Next  day  she  began  to  pass  enormous 
quantities  of  fluid  from  the  urethra,  estimated  at  from  thirty-five 
to  forty-five  pints  in  three  to  four  days,  until  the  abdomen 
became  quite  flat  ;  and  Mr.  Fox  related  the  case  in  the 
*  British  Medical  Journal,'  as  a  case  of  spontaneous  cure  of 
ovarian  cyst.  But  in  October  1863  she  began  to  enlarge  again, 
and  continued  to  increase  until  I  tapped  her  in  July  1865.  After 
this  tapping  she  remained  well  till  the  end  of  1866 ;  then  she 
began  to  refill,  and  during  the  summer  of  1867,  whilst  getting 


166  SUCCESSFUL    CASES    OF   SIMPLE   TAPPING 

into  an  omnibus  at  Portsmouth,  she  fell  and  struck  the 
abdomen  violently.  Soon  afterwards  profuse  diuresis  set  in, 
and  she  was  rapidly  reduced  in  size,  as  before.  In  April  1869 
Mr.  Fox  wrote  :  (  She  continues  quite  well ;  there  has  been  no 
tendency  to  refill  since  she  fell  at  Portsmouth.'  I  heard  of  her 
in  1872  as  continuing  well. 

In  March  1865  I  saw  a  widow,  42  years  of  age,  with 
Dr.  Greenhalgh,  suffering  from  an  ovarian  cyst,  which  filled 
the  abdomen,  and  could  be  felt  low  down  in  the  pelvis  pressing 
the  uterus  forwards  and  upwards,  I  emptied  the  cyst,  by 
tapping,  on  March  25,  1865.  The  fluid  was  dark  brown  in 
colour  and  rather  viscid.  I  fully  expected  that  it  would  soon 
form  again,  but  in  August  she  wrote  to  say  that  '  there  were 
no  signs  of  the  tumour  filling,  and  Dr.  Everet  could  not 
detect  any  fluid  whatever.'  In  April  1869  she  wrote:  'My 
health  has  very  much  improved.  I  have  had  no  return  of  the 
disease.  I  am  in  better  health  than  I  have  been  for  many 
years  past.  In  1867  I  married  again,  and  had  the  advantage 
of  residing  in  a  most  healthy  watering-place  in  the  North  of . 
England,  where  in  a  few  months  I  gained  flesh  and  strength.' 
I  have  reason  to  believe  that  this  patient  remains  quite 
well. 

I  have  selected  these  cases  as  the  earliest  in  my  note-books, 
but  I  have  had  several  other  cases  under  observation  for  shorter 
periods,  where  single  cysts,  after  having  been  emptied  of  limpid 
contents,  have  remained  without  any  signs  of  refilling,  and  the 
patient  has  continued  in  good  health.  In  one  of  the  earliest 
cases,  which  was  published  many  years  ago  by  Mr,  Cooke,  I 
tapped  the  patient  in  the  Samaritan  Hospital  only  the  day 
before  she  was  married.  She  became  pregnant  at  onoe,  and 
has  had  several  children  since,  without  any  sign  of  refilling 
of  the  cyst.  Mr.  Cooke  supposed  that  the  pressure  of  the 
increasing  uterus  had  some  share  in  preventing  the  cyst  from 
refilling, 

It  will  be  seen  by  a  perusal  of  these  cases  and  by  my 
subsequent  experience  that  I  am  quite  in  accord  with  the 
conclusions  drawn  so  recently  by  Dr.  Mehu  from  his  researches 
on  the  abundant  material  supplied  to  him  by  the  hospitals  and 
practitioners  of  Paris,  that  in  spite  of  what  may  be  said  about 
Dr.  Cfreenhalgh's  exceptional  case,  it  is  only  when  single,  and 


INFLUENCE    OF   TAPPING    ON    OVARIOTOMY 


167 


probably  broad  ligament  or  extra-peritoneal  cysts,  are  tapped, 
and  clear,  non-albuminous  fluids  are  evacuated,  there  is  a 
reasonable  hope  of  fluid  not  again  accumulating. 

In  order  to  weigh  the  value  of  the  various  objections  to 
tapping,  I  have  gone  over  the  records  of  my  first  five  hundred 
cases  of  ovariotomy,  and  have  arranged  in  the  following  table 
the  cases  where  tapping  had  never  been  practised,  and  where 
it  had  been  performed  from  one  to  eighteen  times : — 


Cases 

Number 

Recoveries 

Deaths 

Mortality  per  cent. 

Never  tapped 

235 

180 

55 

23-4 

Once  tapped 

HO 

107 

33 

23-57 

Twice  tapped 

49 

32 

17 

34-69 

Three  times  tapped 

32 

25 

7 

21-87 

Four 

15 

10 

5" 

Five              , 

3 

2 

1 

Six                , 

6 

3 

3 

Seven            , 

3 

2 

1 

Eight 

5 

4 

1 

Nine             , 

4 

3 

1 

■ 

34- 

Ten                , 

3 

3 

0 

Eleven          , 

1 

0 

1 

Fifteen 

I 

1 

0 

Sixteen         , 

2 

1 

1 

Eighteen      , 

1 

0 

1J 

500 

373 

127 

25-4 

Two  hundred  and  sixty-five  of  these  five  hundred  patients 
upon  whom  I  have  performed  ovariotomy  had  been  tapped 
previously,  from  one  to  eighteen  times.  One  hundred  and 
ninety-three  of  these  tapped  patients  recovered,  and  seventy- 
two  died,  giving  a  mortality  of  27*16  per  cent. 

It  may  be  seen  that  the  general  mortality  of  the  500  cases 
is  25*4  per  cent.,  and  that  235  patients,  or  nearly  one- 
half,  had  never  been  tapped.  In  them  the  mortality  is  23*4 
per  cent.,  just  2  per  cent,  less  than  the  general  mortality. 
In  other  words,  the  mere  fact  that  a  patient  has  or  has 
not  been  tapped  (so  far  as  can  be  judged  from  500  cases  in 
the  hands  of  the  same  operator)  does  not  affect  the  result  of 
the  operation  by  more  than  2  per  cent.  Indeed  the  mortality 
of  the  patients  not  tapped,  though  less  by  about  10  per  cent, 
than  that  of  the  patients  who  had  been  tapped  twice,  is  greater 
than  that  of  the  patients  who  had  been  tapped  once  and  three 
times.     Thus  140 — or  rather  more  than  one-fourth — had  been 


168  PROPOSITIONS   ABOUT   TAPPING 

tapped  once,  and  the  mortality  was  23*57  per  cent.  Of  32 
who  were  tapped  three  times,  the  mortality  was  21 '87  per  cent. 
Of  the  49  who  were  tapped  twice,  the  mortality  was  nearly  the 
same  as  that  of  the  group  of  cases  tapped  from  4  to  18  times, 
namely  34*69  per  cent.,  or  about  1  in  3. 

I  have  not  extended  this  calculation  over  the  whole  thou- 
sand cases,  because  from  accidental  circumstances  the  record  of 
previous  tappings  has  not  latterly  been  so  complete  as  to 
furnish  very  exact  results  ;  but  an  investigation  of  the  details  so 
far  as  they  are  clear  leaves  an  impression  that  the  aspect  of  the 
question  remains  unaltered. 

It  may  be  taken  then  as  almost  certain  that  the  mortality 
of  ovariotomy  is  but  little  affected  by  tapping— that  the  fact 
of  a  patient  not  having  been  tapped,  or  having  been  tapped 
very  often,  is  by  itself  of  little  Or  no  value  in  prognosis.  I 
have  stated  elsewhere  that  such  adhesions  as  are  apt  to  follow 
tapping  have  no  appreciable  effect  upon  the  mortality  after 
ovariotomy  ;  and  I  can  now  add  that  in  some  of  the  patients 
who  have  been  tapped  most  frequently  there  were  no  adhesions, 
and  there  were  firm  adhesions  in  some  who  had  never  been 
tapped. 

Although  more  impressed  of  late  years  by  the  danger  of 
putrefactive  changes  in  the  fluid  after  tapping  without  anti- 
septic precautions,  I  still  adhere  to  the  following  propo- 
sitions : — - 

1.  That  in  cases  of  simple  ovarian  or  extra-ovarian  cysts,  it 
is  right  to  try  the  effect  of  one  tapping  before  advising  a 
patient  to  undergo  a  more  serious  risk.  But  in  compound  or 
multilocular  cysts  the  third  proposition  holds  good. 

2.  That  one  or  many  tappings  do  not  increase  considerably 
the  mortality  of  ovariotomy. 

3.  That  tapping  may  sometimes  be  a  useful  prelude  to 
ovariotomy,  either  as  a  means  of  gaining  time  for  a  patient's 
general  health  to  recover,  clearing  the  mine  of  the  load  of 
albumen  with  which  it  is  sometimes  charged  under  the  mere 
influence  of  pressure,  or  of  lessening  shock,  by  relieving  her  of 
the  fluid  a  few  hours  or  days  before  removing  the  solid  portion 
of  an  ovarian  cyst ;  and 

4.  That  when  the  syphon-trocar,  which  I  brought  before  the 
profession  in  1860,  i^  carefully  used  in  such  a  manner  as  to 


TAPPING  THEOUGH  THE  VAGINA  169 

prevent  the  escape  of  ovarian  fluid  into  the  peritoneal  cavity, 
and  the  entrance  of  air  or  of  putrefactive  material  into  the  cyst, 
the  danger  of  tapping  is  extremely  small. 


TAPPING   THROUGH    THE    VAGINA 

is  much  more  liable  to  be  followed  by  inflammation  of  the  cyst 
than  tapping  through  the  abdominal  wall,  because  it  is  not  easy 
to  prevent  the  entrance  of  air.  We  should  always  endeavour  to 
avoid  this  accident  by  attention  to  the  level  of  the  canula, 
but  the  attempt  does  not  invariably  succeed.  The  operation  of 
tapping  through  the  vagina  is  selected,  not  so  much  with  the 
intention  of  simply  emptying  the  cyst,  as  for  the  chance  that, 
should  the  fluid  escape  by  the  opening  as  fast  as  it  is  secreted, 
the  cyst  may  gradually  contract  and  the  puncture  close.  This 
favourable  result,  however,  is  seldom  secured.  As  a  rule,  air 
enters  the  cyst,  the  opening  fills  up,  and  the  fluid  remaining 
in  the  cyst,  or  that  freshly  secreted,  putrefies.  Suppurative 
inflammation  of  the  lining  membrane  of  the  cyst  comes  on, 
and  is  accompanied  by  a  low  form  of  septic  fever  or  pyaemia, 
which  can  only  be  relieved  by  making  and  maintaining  a  free 
outlet  for  the  discharge.  The  frequency  of  these  consequences 
should  make  tapping  through  the  vagina  an  exceptional  prac- 
tice. But  it  may  be  adopted  in  cases  where  an  ovarian  cyst 
is  bound  down  in  the  pelvis  by  adhesions,  and  it  is  necessary 
to  relieve  the  distress  caused  by  pressure  on  the  bladder  and 
rectum.  The  puncture  should  then  be  made  where  the  fluc- 
tuation is  most  evident,  but  as  near  the  median  line  as 
possible.     The  canula,  or  an  elastic  catheter,  may  be  left  in  the 


cyst,  though  it  is  safer  practice  either  to  introduce  a  wire  seton, 
or  a  drainage  tube,  so  as  to  prevent  the  opening  from  closing, 
and  make  Bltfe  of  the  free  and  immediate  escape  of  aDy  fluid 


170  CASE    OF   TAPPING   THROUGH   THE   VAGINA 

that  may  be  secreted.  Whether  a  eanula  or  tube  be  used,  it 
is  necessary  to  adopt  some  contrivance  to  prevent  it  from 
slipping  out ;  and  I  find  a  piece  of  wire  doubled  at  the  inner 
end  answers  this  purpose  well.  The  ends  open  out,  as  shown  in 
this  drawing,  when  passed  beyond  the  end  of  the  eanula  or  tube, 
and  maintain  either  in  the  cavity  until  the  wire  is  withdrawn. 

Many  years  ago,  before  I  had  much  experience  in  ovariotomy, 
I  saw  a  lady  with  Dr.  West,  whose  case  appeared  to  us  both  to 
be  a  very  favourable  one  for  the  operation  ;  but  as  fluctuation 
could  be  distinctly  felt  through  the  vagina,  we  both  thought 
that  tapping  by  the  vagina  might  be  less  hazardous  than 
ovariotomy,  and  I  accordingly  emptied  the  cyst  by  vaginal 
tapping.  Complete  relief  was  afforded,  but  only  for  a  short 
time.  Symptoms  of  suppurative  inflammation  of  the  cyst 
showed  themselves,  and  much  purulent  matter  was  removed 
at  the  second  tapping.  The  patient  went  to  Bristol,  and  was 
most  ably  attended  there  by  Mr.  Cross,  the  discharge  being 
persistently  kept  up;  but  she  died  in  about  a  year.  The 
detailed  notes  of  the  case  have  been  lost,  but  I  have  not 
forgotten  the  impression  which  it  made  upon  me. 

In  the  following  case,  vaginal  tapping  and  drainage  was 
completely  successful  in  leading  to  a  perfect  cure.  In  June 
1861  I  was  consulted  by  a  lady,  32  years  of  age,  on  account 
of  an  abdominal  tumour  which  extended  just  above  the  um- 
bilicus, rather  more  to  the  left  than  to  the  right  side,  and 
which  completely  filled  the  pelvis.  She  had  been  married  ten 
months  when  she  consulted  me,  and  two  months  before  marriage 
she  had  consulted  an  eminent  physician  who  said  that  she  had 
a  small  fibroid  tumour  of  the  uterus,  that  she  might  marry, 
but  that  she  was  not  likely  to  have  children.  Soon  after  mar- 
riage the  tumour  increased,  particularly  towards  the  left  side, 
and  pressure  on  the  bladder  led  to  retention  of  urine  and  cathe- 
terism.  In  March,  Dr.  Ferguson  said  it  was  a  fibrous  tumour 
which  had  better  be  left  alone.  Soon  afterwards,  Dr.  Waller 
said  she  had  both  an  ovarian  and  a  fibrous  tumour,  and  two 
days  before  I  saw  her  Mr.  Baker  Brown  said  she  had  a  fibrous 
tumour  which  he  proposed  to  '  gouge.'  My  first  impression 
was  that  the  tumour  was  ovarian,  closely  attached  to  the 
uterus,  but  not  a  uterine  tumour.  I  saw  her  occasionally 
during  the  next   six   months,    the  abdominal  portion  of  the 


CASE    OF   TAPPING   THROUGH   THE   VAGINA  171 

tumour  increasing,  and  the  pelvic  portion  becoming  harder 
and  pushing  the  uterus  closer  to  the  symphysis  pubis.  In 
March  1862,  vomiting  and  other  symptoms  having  become 
distressing,  vaginal  tapping  was  agreed  upon  in  consultation 
with  Dr.  West.  On  March  20,  I  passed  a  trocar  into  the  most 
prominent  part  of  the  swelling  in  the  posterior  vaginal  wall. 
About  ten  ounces  only  of  thick  bloody  fluid  came  away.  The 
next  day  she  was  pretty  well.  On  the  22nd,  the  catamenia  came 
on  with  sickness.  On  the  25th,  vomiting  was  increased,  but  was 
relieved  next  day  after  iced  champagne,  and  using  turpentine 
injections.  On  the  27th,  a  very  copious  vaginal  discharge 
came  on  with  some  odour.  On  April  5,  Dr.  Bunce,  of  Woodford, 
wrote :  '  The  discharge  still  continues,  and  has  done  so  all  the 
week ;  she  has  been  very  weak  at  times  and  faint.'  On  the 
7th,  he  wrote  again  :  'The  discharge  has  continued  till  this 
morning,  thinner  and  lighter  in  colour,  and  excessively  fetid ; 
there  is  now  but  little  discharge,  with  less  fetor  ;  there  is  con- 
siderable diminution  in  the  size  of  the  abdomen,  which  is  soft 
and  flaccid  except  on  the  left  side,  where  there  is  a  hard  lump. 
Sickness  has  ceased,  she  takes  plenty  of  nourishment,  and  is  in 
good  spirits.'  On  the  11th,  I  found  her  up  and  pretty  well. 
There  was  still  some  swelling  in  the  left  iliac  region,  but  all 
the  rest  of  the  abdomen  was  clear  on  percussion  ;  discharge 
had  almost  ceased,  and  the  uterus  was  nearly  in  its  normal 
position,  but  large  and  low  down.  She  went  on  well  till  the 
16th,  when  fetid  ovarian  fluid  again  began  to  escape  by  the 
vagina,  She  was  sick  and  weak  for  some  days,  but  went  to 
Brighton  in  May,  and  returned  in  June,  a  little  discharge  still 
continuing.  In  July  some  abdominal  swelling  low  down 
could  still  be  felt,  but  she  was  in  excellent  health.  In  August, 
symptoms  of  early  pregnancy  showed  themselves.  In  Septem- 
ber, there  was  smart  flooding,  and  apparently  an  abortion  of 
about  ten  weeks.  In  October,  there  was  excessive  catamenial 
discharge,  lasting  six  days.  In  the  spring  of  1863,  she  again 
became  pregnant,  and  all  through  her  pregnancy  had  occasional 
discharges  from  the  rectum  of  what  appeared  to  be  ovarian 
fluid,  but  a  healthy  child  was  born  on  December  29,  1863,  and 
Dr.  West  informed  me  that  the  labour  was  quite  natural.  A 
second  child  was  born  in  1865,  and  a  third  in  1866.  Two 
other  children   have  been  born   since,  the  last  in  May   1870  5 


172  VAGINAL   TAPPING 

and  she  remained  quite  well  till  1879,  when  she  died  of  some 
other  disease. 

In  April  1862  a  married  woman,  30  years  of  age,  was  in 
the  Samaritan  Hospital  with  an  ovarian  tumour,  which  occupied 
the  whole  of  the  left  side  of  the  abdomen,  and  could  be  felt 
by  the  vagina  and  rectum  behind  the  uterus,  quite  filling  up 
the  pelvis.  She  had  suffered  considerably  from  the  pressure  of 
this  tumour  for  about  four  years.  On  April  17,  I  tapped  with 
Scanzoni's  trocar  behind  the  uterus,  but  only  about  a  pint  of 
ovarian  fluid  escaped.  She  left  the  hospital  in  a  few  days 
much  relieved.  I  heard  afterwards  that  vaginal  discharge  con- 
tinued for  a  considerable  period,  and  became  purulent,  that  the 
abdominal  tumour  gradually  disappeared,  and  that  she  regained 
good  health.  I  have  lost  sight  of  her,  and  on  writing  to  her 
address  the  letter  was  returned,  marked  '  Gone  away.' 

In  August  1866, 1  saw  a  young  married  lady  with  a  circum- 
scribed collection  of  fluid  in  the  right  iliac  region.  She  was 
married  in  May  1861,  went  to  Ireland  in  the  following  Sep- 
tember, was  taken  ill  there  with  irritable  bladder,  scanty  urine, 
and  difficulty  in  passing  it ;  suffered  a  good  deal  during  a 
voyage  to  India;  and,  on  landing  at  Bombay  in  1862,  a  basin 
full  of  '  white  stuff  like  matter '  came  away  by  the  rectum. 
After  this  she  was  well  till  December  1865,  when  increase  in 
the  abdomen  began  as  she  was  travelling  in  India,  and  con- 
tinued slowly  until  I  saw  her.  On  August  14,  1866,  I  tapped 
with  a  very  fine  trocar  just  above  the  pubes,  on  the  right  side, 
and  removed  with  an  exhausting  syringe  three  pints  of  ovarian 
fluid.  Immediate  relief  was  obtained,  and  she  felt  quite  well 
till  November.  Then  some  pain  and  swelling  began  on  the 
left  side,  just  behind  the  left  hip,  in  the  same  place  that  she 
felt  it  when  going  to  India  in  1862  ;  but  I  could  not  detect 
any  abdominal  or  pelvic  tumour  except  a  little  thickening 
in  front  of  the  cervix  uteri.  After  this  she  was  occasionally 
treated  by  Dr.  Priestley  for  dysmenorrhoeal  pains ;  and  I  did  not 
see  her  again  till  March  1868,  when  I  examined  her  in  con- 
sultation with  Dr.  Priestley.  She  then  had  an  elastic  tumour 
of  about  the  size  and  situation  of  the  gravid  uterus  of  six 
months.  The  right  side  of  the  vagina  was  deeply  depressed, 
pushing  over  the  uterus  to  the  left.  Distinct  fluctuation  was 
perceptible   from   the  abdomen  to  the  vagina.     We  agreed  to 


AND    DRAINAGE  173 

tap  by  the  vagina,  and  drain  the  sac  after  the  next  menstrual 
period.  On  March  18,  1868,  I  introduced  Scanzoni's  trocar 
to  the  left  of  the  uterus,  and  removed  three  and"  a  half 
pints  of  clear  ovarian  fluid,  leaving  the  elastic  canula  in  the 
cyst  and  vagina.  On  the  19th  and  20th,  she  was  rather 
feverish.  On  the  21st,  I  injected  some  weak  solution  of  iodine. 
On  the  22nd,  no  discharge  coming  through  the  tube,  I  removed 
it.  As  it  came  away  several  ounces  of  fluid  escaped,  as  if  from 
Douglas's  space  rather  than  from  a  cyst.  She  was  feverish, 
with  a  coated  tongue  and  rapid  pulse,  and  went  on  till  the 
27th  without  any  vaginal  discharge.  There  was  increasing 
tension  over  the  pubes,  but  with  clear  sound  on  percussion,  as 
if  air  were  in  the  cyst.  Dr.  Priestley  succeeded  in  introducing 
a  uterine  sound  through  the  vaginal  opening.  Some  gas  and 
fetid  fluid  escaped.  On  the  28th,  I  put  in  a  vulcanite  tube, 
and,  with  a  syringe  fitted  to  it,  drew  out  several  ounces  of  very 
fetid  fluid  with  bubbles  of  gas.  I  repeated  this  on  the  two 
following  days,  the  tube  being  left  in  the  cyst,  and  free  puru- 
lent discharge  going  on  through  it.  On  April  2,  the  nurse 
accidentally  pulled  out  the  tube.  In  the  afternoon  I  found 
that  a  full  inch  of  the  tube  was  broken  off,  and  as  it  could  not 
be  found  we  feared  that  it  might  be  in  the  cyst.  On  April  3, 1 
put  in  a  laminaria  tent  to  enlarge  the  opening.  On  the  4th,  I 
proceeded  to  remove  the  tent,  but  the  string  attached  to  it  cut 
through  the  softened  laminaria,  and  the  tent  was  left  inside 
the  cyst.  I  tried  to  catch  it  with  forceps,  but  could  not ;  so  I 
introduced  a  sponge  tent  in  order  to  widen  the  opening  still 
further.  On  the  5th,  Dr.  Junker  administered  chloroform,  and 
I  dilated  the  opening  by  the  hysterotome  ;  but  neither  with  my 
finger,  nor  forceps,  nor  with  the  lithotrite,  could  I  find  the  lami- 
naria tent,  and  I  supposed  that  the  vegetable  matter  must  have 
been  softened  and  come  away  with  the  discharge.  The  cavity 
felt  large,  but  so  circumscribed  that  it  was  clearly  a  cyst  and 
not  Douglas's  space.  I  put  in  one  of  Dr.  Wright's  steel  ex- 
panding stem  dilators.  This  remained  for  a  fortnight,  and  I 
removed  it  on  April  20.  All  that  time  fetid  purulent  dis- 
charge had  gone  on,  more  or  less  with  occasional  pain  and 
want  of  appetite,  and  something  hard  could  be  felt  to  the 
right  side  of  the  uterus  as  if  the  laminaria  tent  were  still 
there.     She  went  to  Brighton   ->  nd  called  on  me  on  May  14,  on 


174  VAGINAL   TAPPING 

her  return,  much  improved  in  health.  The  discharge  had 
almost  ceased ;  there  was  no  abdominal  swelling ;  but  I  could 
distinctly  feel  something  hard  close  to  the  opening  in  the 
vagina  and  to  the  right  side  of  the  uterus.  Fearing  to  do 
harm  by  attempting  to  remove  it,  if  it  were  the  tent,  I  advised 
her  to  go  into  the  country.  She  wrote  to  me  in  June  that  she 
was  gaining  strength,  but  that  the  discharge  continued  yel- 
lowish and  not  offensive,  and  in  larger  quantities  soon  after  the 
monthly  periods.  I  did  not  hear  of  her  again  till  Dr.  Priestley 
wrote  to  me  in  January  1869,  saying  '  Our  old  patient  came  to 
me,  complaining  of  much  discomfort,  and  copious  discharge 
mixed  with  blood.  I  found  some  foreign  body  lying  in  the 
fistulous  opening,  and  after  a  little  trouble  caught  it  with  a 
pair  of  forceps.  It  turned  out  to  be  the  missing  laminaria 
tent,  which  must  have  been  there  since  last  March.  It  still 
retained  its  form,  and  although  slightly  fetid,  was  much  less  so 
than  one  might  have  expected.  She  was  here  again  to-day, 
much  relieved,  and  the  aperture  seems  disposed  to  contract.' 
She  soon  regained  good  health,  and  I  saw  her  in  the  summer 
of  1871  perfectly  well,  no  sign  of  abdominal  or  pelvic  tumour 
being  discoverable.     I  heard  of  her  lately  in  good  health. 

In  the  following  case  vaginal  tapping  and  drainage  were 
followed  by  good  health  for  three  years,,  but  the  patient  then 
died  with  symptoms  of  pyasmia  and  abscess  of  the  liver.  A 
married  woman,  36  years  old,  was  sent  to  me  by  Mr. 
Chesterman,  of  Banbury,  and  was  admitted  to  the  Samaritan 
Hospital  in  December  1863.  She  had  a  tense,  tender  tumour 
on  the  left  side  of  the  abdomen,  extending  as  high  as  the 
umbilicus*  The  anterior  wall  of  the  vagina  was  depressed, 
especially  on  the  left  side ;  the  uterus  Was  very  high,  so 
that  it  could  scarcely  be  reached  by  the  finger,  and  the  bladder 
was  pulled  up  with  it.  Catamenia  quite  regular.  The  symp- 
toms had  not  been  complained  of  more  than  six  months.  On 
January  4,  1864,  I  tapped  in  the  middle  line  of  the  vagina  and 
evacuated  thirty  ounces  of  green,  albuminous  fluid,  sp.  gr.  1025. 
A  canula  was  left  in  the  cyst  and  fixed  there.  She  had  a 
restless  night ;  slight  rigor  and  some  pain  the  next  day.  On 
the  6th,  iodine  solution  was  injected  through  the  canula  night 
and  morning ;  7th,  scarcely  any  pain,  and  the  canula  caused  no 
annoyance.      Two   hours   after   the   injection   of  iodine   pain 


AND    DRAINAGE  175 

became  severe,  and  was  followed  by  profuse  sweating  ;  8th, 
nothing  having  come  through  the  canula  since  the  iodine  was 
injected,  it  was  removed,  and,  after  its  removal,  some  greenish, 
albuminous  fluid  continued  to  drain  away  for  the  next  two 
days.  The  discharge  ceased,  and  she  was  pretty  well  till  the 
18th,  but  suffering  occasionally  from  pain  and  feverishness. 
On  the  18th,  after  an  attack  of  violent  pain  and  vomiting, 
profuse  and  very  offensive  vaginal  discharge  took  place,  and 
continued  on  the  19th.  On  the  20th,  there  was  severe  pain  in. 
the  left  shoulder,  which  continued  on  the  21st,  but  without 
sweating.  On  the  22nd,  the  pain  in  the  shoulder  subsided, 
and  the  discharge  became  less  offensive ;  but  from  the  23rd  to 
the  27th  it  was  very  free,  purulent,  and  excessively  offensive. 
She  expressed  a  great  wish  to  return  home,  and  did  so  on 
February  2,  improved  in  general  condition,  but  with  a  very 
offensive  discharge  continuing.  At  the  end  of  a  month,  Mr. 
Chesterman  wrote  that  she  was  '  getting  fat  and  strong,  and 
saying  that  she  felt  better  than  she  had  been  for  the  last 
ten  years.'  I  heard  of  her  again  in  June  1865,  when  she 
said  she  had  remained  well  till  a  month  before,  when  she 
had  some  fetid  discharge,  which  lasted  for  three  weeks,  and 
then  ceased.  The  uterus  felt  fixed,  but  there  was  no  other 
sign  of  disease.  On  November  15,  1867,  Mr.  Pemberton, 
of  Banbury,  wrote  to  say  that  this  patient  had  died  after 
an  illness  of  about  ten  days.  '  She  had  been  exceedingly 
well  for  twelve  months  or  more  prior  to  this  attack  ;  the 
tumour  had  become  so  small  as  scarcely  to  be  felt  through 
the  abdominal  parietes  ;  and  she  rarely  had  any  pain,  but 
occasionally  a  little  uneasiness  followed  by  a  discharge  from 
the  vagina,  when  all  felt  well  again.  She  had  been  out  for  many 
hours  in  the  wet,  and  was  seized  with  acute  pain  over  the 
hepatic  region,  and  great  tenderness  down  the  right  side  towards 
the  hip.  The  tumour,  you  will  remember,  was  on  the  left 
side  ;  all  her  pain  now  was  referred  to  the  right  side,  immediately 
below  the  ribs ;  and,  a  day  or  two  before  death,  there  was 
oedema,  extending  from  the  hepatic  region  to  the  right  thigh, 
limited  to  the  right  side  only.  Mr.  Chesterman  concluded 
from  this,  that  there  was  some  obstruction  to  the  circulation, 
and  probably  abscess  in  the  liver.  I  very  much  regret  to  add, 
that  I  was  unable  to  obtain  a  post-mortem  examination.'  Whether 


176  TAPPING   THROUGH   THE    RECTUM 

a  freer  opening  in  this  case  might  have  prevented  the  re-forma- 
tion of  fluid  or  pus  in  the  cyst  is  a  question  which  suggests 
itself;  and  I  may  state  that  the  impression  left  on  my  mind  by 
what  I  have  seen  of  vaginal  tapping,  leads  me  to  the  conclusion 
that  simple  tapping  is  more  hazardous  than  tapping  followed 
by  drainage,  and  that  drainage  should  be  so  complete  that  no 
reaccumulation  of  fluid  can  take  place,  the  cavity  being  kept 
open  until  its  walls  collapse  and  unite,  so  that  it  is  completely 
obliterated.  Even  then  patients  are  so  apt  to  suffer  from  some  of 
the  ill-effects  of  long-continued  suppurative  processes,  that  I 
am  more  than  ever  confirmed  in  the  opinion  that  it  is  better, 
even  at  considerable  risk,  to  remove  a  cyst,  if  at  all  possible, 
than  to  trust  to  any  mode  of  drainage. 

TAPPING   THROUGH   THE   RECTUM 

has  been  supposed  to  possess  some  advantages  over  tapping 
through  the  vagina.  It  was  said  that  there  would  be  no  con- 
stant discharge  of  offensive  fluid,  for  any  ovarian  fluid  which 
entered  the  rectum  would  be  retained,  just  as  a  liquid  motion 
is  retained  by  the  sphincter  ani,  and  discharged  when  the 
patient  pleased.  But  a  dysenteric  tenesmus  has  been  occa- 
sionally observed,  which  has  proved  very  distressing,  and  fatal 
inflammation  has  followed  entrance  of  fascal  gases  into  the 
cyst.  I  had  one  such  case  with  Dr  Priestley.  We  tapped  an 
adhering  cyst  through  the  rectum,  and  the  patient  died  some 
days  afterwards  of  cyst  inflammation.  The  cavity  was  filled 
with  fsecal  gas. 

It  was  supposed  that  the  objection  to  vaginal  tapping  from 
entrance  of  air  into  the  cyst  would  be  guarded  against  in  rectal 
tapping  by  the  contraction  of  the  sphincter  ani.  But  the 
entrance  of  faecal  gas  into  a  cyst  would  be  quite  as  likely  to 
occur,  and  would  probably  be  more  injurious  than  the  entrance 
of  atmospheric  air  in  vaginal  tapping. 

INJECTION   OF   IODINE. 

Notwithstanding  the  strenuous  advocacy  of  Boinet,  the 
practice  of  injecting  ovarian  cysts  with  iodine  has  quite  fallen 
into  desuetude,  and,  so  far  as  my  own  trials  and  means  of  obser- 
vation enable  me  to  judge,  not  in  any  way  to  the  disadvantage 


INJECTION   OF   IODINE  177 

of  patients.  The  few  cysts  which  I  injected  and  which  did  not 
refill  for  several  years,  were  single,  with  limpid  contents  ;  and 
in  such  cysts  I  believe  simple  tapping  is  quite  as  effectual  alone 
as  it  is  with  the  injection  of  iodine  in  addition. 

The  only  cases  in  which  iodine  injection  is  really  useful,  and 
where  its  employment  should  be  recommended,  are  those  in 
which,  after  tapping  either  by  the  abdominal  wall,  vagina,  or 
rectum,  cyst  inflammation  has  occurred,  and  the  patient  is 
suffering  from  absorption  of  the  decomposing  contents  of  the 
cyst.  Here  free  drainage  becomes  necessary  to  save  the 
patient  from  pyaemia  or  septicaemia ;  but  she  may  suffer 
considerably  in  appetite  and  strength  if  the  fluid  which 
escapes  is  offensive;  and  it  ought  to  be  deodorized.  For 
this  purpose  iodine,  or  phenol,  or  sulphurous  acid,  or  chromic 
acid  may  be  used  in  tolerably  strong  solution ;  and  iodine  I 
used  to  think  preferable  to  all  the  others.  A  solution  of  one 
part  of  iodine  and  two  of  iodide  of  potassium  to  twenty  parts 
of  water  was  used  night  and  morning,  injected  through  the 
catheter  after  washing  out  the  cyst  with  warm  water ;  and  the 
greater  part  of  the  iodine  solution  injected  allowed  to  run  away 
again  at  once.  But  a  little  was  left  in  the  cyst,  partly  to  act 
on  its  walls  and  partly  to  deodorize  the  fluid  contents  of  the 
cyst  if  they  putrefied.  Latterly  I  have  had  reason  to  prefer 
sulphurous  acid  to  iodine.  I  have  used  with  excellent  effect 
a  mixture  of  one  part  of  the  acid  of  the  British  Pharmacopoeia 
with  six  or  eight  parts  of  tepid  water. 

TREATMENT   BY   INCISION. 

The  practice  of  laying  open  ovarian  cysts  by  incision  no 
doubt  arose  when,  during  tapping,  the  instrument  used  proved 
to  be  too  small  for  the  escape  of  thick  fluid.  On  withdrawing 
the  canula  it  would  be  found  filled  with  glue-like  matter,  and 
similar  matter  would  be  observed  exuding  from  the  opening. 
The  natural  result  would  be  that  the  surgeon  would  enlarge 
the  opening,  until  the  contents  of  the  cyst  could  escape  or  be 
squeezed  out.  This  has  occurred  to  me  more  than  once.  I 
was  present  when  Mr.  Armstrong  Todd  tapped  a  young  lady. 
After  a  little  fluid  had  escaped,  the  canula  became  clogged  with 
hair  and  fat,  and  it  was  withdrawn.     Fluid  continuing  to  ooze 

N 


178  INCISION   AND   DRAINAGE 

away,  the  opening  was  enlarged  until  first  one  finger,  then  two, 
and  then  a  tablespoon  could  be  used  to  scoop  out  many  pounds 
of  semi-solid  fat,  with  masses  of  hair  and  bony  spiculse,  from 
a  cyst  which  was  intimately  adhering  over  a  large  extent  of 
the  abdomen.  Ovariotomy  was  proposed  to  the  parents,  but 
as  the  unfavourable  conditions  were  explained  to  them  at  the 
same  time  as  the  possibility  of  a  cure  by  the  incision  was  also 
pointed  out,  they  preferred  the  latter  alternative,  and  the  patient 
only  survived  a  few  days. 

In  another  case,  with  Mr.  Taunton,  of  the  Commercial  Eoad, 
where  the  contents  of  a  large  cyst  consisted  of  very  thick  col- 
loid, I  made  an  incision  of  about  two  inches  long,  and  squeezed 
out  many  pounds  of  matter  as  thick  as  calf's-foot  jelly.  In 
this  case  considerable  relief  was  given  for  a  time,  but  the 
patient  ultimately  died  exhausted  from  the  continuous  dis- 
charge. 

In  the  cases  hereafter  described,  where  it  has  been  impossible 
to  complete  ovariotomy,  and  the  cyst,  or  a  portion  of  it,  has  been 
left  within  the  abdominal  cavity,  the  edges  of  the  opening  in 
the  cyst  have  been  fixed  to  the  abdominal  wall  by  suture,  and 
such  cases  t^ave  become  similar  to  those  treated  by  incision.  I 
have  not  adopted  the  practice  under  any  other  circumstances, 
but  it  has  been  repeatedly  done  by  others,  and  various  means 
have  been  taken  to  prevent  the  escape  of  the  fluid  into  the 
abdominal  Gavity.  Adhesion  between  the  cyst  and  the  ab- 
dominal wall  has  been  secured  by  caustic  issues,  or  by  the 
insertion  of  needles,  or  by  the  use  of  special  instruments,  or  by 
suture  after  laying  bare  the  cyst.  As  soon  as  adhesion  was 
believed  to  be  complete,  the  incision  was  made,  and  the  cyst 
kept  open  until  the  obliteration  of  its  cavity  took  place.  So 
far  as  I  can  learn,  from  my  own  experience  and  the  study  of 
recorded  cases,  this  practice  is  far  more  dangerous  than  ovari- 
otomy, and  very  much  less  likely  to  be  followed  by  complete  cure. 
I  think,  therefore,  it  should  only  be  considered  admissible  in 
cases  where  ovariotomy  cannot  be  completed.  Then  after 
incision  and  emptying  the  cyst  as  far  as  possible,  and  securing 
the  opening  in  the  cyst  to  the  opening  in  the  abdominal  wall, 
the  cavity  is  kept  empty  by  draining  and  the  injection  of  disin- 
fectino-  or  deodorizing  agents.  The  conditions  are  then  the 
same  as  those  of  a  drained  abscess. 


HISTORICAL   NOTES   ON   OVARIOTOMY  179 


CHAPTER  V. 

THE  RISE   AND   PROGRESS   OF   OVARIOTOMY. 

Ovariotomy.  From  wdpiov^  ovary ;  and  To/itf ,  incision.  [Syn. 
Ovariotomie,  Fr.  and  Grer. — Ovariotomia,  Ital.  and  Sp.]  Defi- 
nition :  The  operation  for  the  removal  of  one  or  both  ovaries* 
As  it  is  only  performed  by  surgeons  when  one  or  both  ovaries 
are  diseased,  it  is  a  very  different  proceeding  from  the  extirpa- 
tion of  healthy  ovaries,  which  has  been  practised  from  remote 
antiquity  to  the  present  time  on  domestic  animals  for  eco- 
nomical purposes,  and  both  in  ancient  periods  and  in  the 
middle  ages  on  women,  almost  exclusively  for  immoral  pur- 
poses. Galen,  in  his  work  'De  Semine,'  records  that  in 
Eastern  Asia  and  in  Cappadocia,  sows  were  spayed  in  order 
to  fatten  them,  and  to  improve  the  flavour  of  their  meat.  He 
also  points  out  the  greater  difficulty  and  danger  of  this  opera- 
tion than  the  castration  of  male  animals:  'Non  turn  ita 
tutum  in  foeminis  testium  extractio  administrari  potest  ob 
sedem  in  qua  collocati  sunt ;  .  .  .  majusque  in  hoc  quam  in 
maribus  periculum  est.' 

"We  find  a  passage  in  Pliny's  *  Historia  Animalium '  (lib. 
viii.  c.  77) : — ■*  Castrantur  suis  foeminae  quoque,  sicuti  cameli, 
post  bidui  inediam  suspensse  pernis  prioribus,  vulva  recisa; 
celerius  ita  pinguescunt,'  which  appears  dubious,  whether 
castration  or  infibulation  is  alluded  to. 

In  Book  ix.  of  Uspl  Zcomv  'laroplas  of  Aristotle,  the  cas- 
tration of  cows  and  camels  is  mentioned. 

Athenseus,  in  Asnrvoo-ocfiio-TOJv  (lib.  xii.  c.  9),  relates  a  story 
of  Andramystes,  a  Lydian  king,  who  kept  castrated  females 
instead  of  eunuchs  in  the  service  of  his  harem ;  and  Gyges, 
another  Lydian  king,  is  reported  to  have  had  several  of  his 

N  2 


180  CASTEATION   OF   WOMEN   AMONG   SAVAGES 

concubines  castrated,  in  order  to  prolong  the  charms  of  their 
youth. 

Omitting  some  apocryphal  records  of  later  periods,  we  pass 
on  to  several  writers  of  the  seventeenth  and  eighteenth  cen- 
turies, as  Vierus,  Eiolan  ('Opera  prima,' Paris,  1610;  'Ana- 
tome,'  p.  142),  Diemerbroeck  ('  Anatomia   corporis   humani,' 
Lyon,  1679  ;  I.  I.  c.  xxiii.),  Boerhave  ('Prselect.  Academ.  in 
prop,    inst.'   f.    5,   pars   2   and    669),   Graaf  ('De   Mulierum 
Organ.  Grenerat.  inserv.  Tract,  nov.'  cap.  13),  Plater  ('  Observ. 
libri  tres,'  Basle,  1680,  p.  248),  &c,  who  either  mention  the 
extirpation  of  the  ovaries  as  having  been  performed,  or  propose 
this  operation  in  the  treatment  of  nymphomania.     And  at  the 
present  day  it  seems  to  be  a  common  practice  among  some  of 
the  natives  at  the  antipodes.     Dr.  Junker  writes  me  word  that 
a  paper  was  laid  before  a  late  meeting  of  the  Anthropological 
Society  of  Berlin  for  publication  in  their  Transactions  which 
reports  that  the  aborigines  of  Australia  and  of  New  Zealand 
perform  ovariotomy  on  young  girls  (the  age  is  not  mentioned) 
by  incision  in  both  inguinal  regions.     They  do  this  for  two 
purposes  :  first,  to  prevent  the  propagation  of  hereditary  diseases 
and   deformities   and  other   disabilities.      The  writer  met   a 
woman  born  deaf  and  dumb  who  had  been  spayed  to  hinder 
her  from   bearing   deaf  and   dumb   children.      Their   second 
object  is  to  keep  up  a  supply  of  barren  prostitutes  who  live 
excluded  from  the  society  of  other  females  and  associate  with 
the  unmarried  men,  whom  they  follow  in  the  bush.     These 
women  have  their  breasts   either  undeveloped  or  very  small, 
from  which  it  is  inferred  that  they  are  mutilated  at  different 
ages.     They  never  grow  very  fat,  and  the  buttocks  do  not 
become  so  large  as  those  of  other  women.     They  are  however 
strong  and  capable  of  bearing  great  fatigue.     For  the  same 
reason  of  personal  defect  men  are  made  impotent  by  slitting  up 
the  urethra  as  far  as  the  membranous  part ;  and  if  they  marry 
and  wish  to  perpetuate  their  name  custom  authorizes  their  wives 
to  cohabit  with  other  men. 

So  far,  by  all  these  writers,  the  removal  of  sound  ovaries 
from  strong  and  healthy  individuals,  placed  under  the  most 
favourable  circumstances,  was  proposed  or  commented  on.  In 
the  present  day  a  diseased  organ  is  extirpated  from  a  person 
more  or  less  weakened  and  distressed  by  long  sufferings,     The 


OVARIOTOMY    PROPOSED   FOR   DISEASE  181 

ancient  operation  was  the  pander  to  luxurious  vice  and  immo- 
rality. Modern  ovariotomy,  when  successful,  rescues  the  victim 
from  otherwise  hopeless  suffering  and  certain  death,  and,  even 
when  unsuccessful,  mercifully  shortens  her  martyrdom. 

It  was  not  earlier  than  in  the  seventeenth  and  eighteenth 
centuries  that  ovariotomy  was  proposed  and  suggested  as  a 
radical  cure  for  diseased  ovaries.  As  late  as  the  beginning  of 
the  eighteenth  century,  this  operation  was  first  performed,  and 
it  remained  long  in  discredit.  It  is  only  within  the  last  five- 
and-twenty  years  that  it  has  been  at  all  frequently  or  generally 
practised. 

Theodor  Schorkoff,  in  his  *  Dissertatio  medica  inauguralis  de 
Hydrope  Ovarii '  (Sept.  7,  1685),  expresses  the  belief  that  the 
extirpation  of  dropsical  ovaries  would  lead  to  a  permanent  cure, 
if  the  operation  itself  were  less  cruel  and  hazardous. 

Schlenker,  in  the  21st  thesis  of  his  dissertation  'De  sin- 
gulari  ovarii  sinistri  morbo '  (1722),  proposes  the  question 
whether  a  radical  cure  of  diseased  ovaries  might  not  be  effected 
by  the  removal  of  the  organ  through  an  incision  in  the  ab- 
domen ;  but  he  leaves  the  answer  to  his  more  experienced 
colleagues. 

Soon  after  him,  Willius,  of  Basle,  published  (in  1731)  a 
pamphlet,  '  Specimen  medicum  sistens  stupendum  abdominis 
tumorem,'  which  contains  the  following  passage:  'When, 
however,  the  dropsy  fills  all  the  chambers  of  the  ovary,  when 
the  fluid  is  thick  and  viscid,  and  no  hope  of  recovery  is  enter- 
tained, we  question  whether  such  an  ovary  ought  not  to  be 
extirpated,  and  so  the  root  and  cause  of  the  disease  be  removed. 
We  know  from  experience  that  severe  and  large  abdominal 
wounds  have  healed  ;  they  are  not  likely  to  prove  more  dan- 
gerous in  the  case  of  attempting  a  cure  by  excision  of  the  ova- 
ries.' Notwithstanding  this  advanced  view,  he  still  shrank 
from  the  execution  of  the  operation,  afraid  of  the  extent  of  the 
incision  required  to  remove  large  tumours  ;  of  the  adhesions 
likely  to  be  met  with  ;  the  pain  inflicted ;  the  haemorrhage, 
the  exposure  of  the  abdominal  viscera,  and  its  fatal  conse- 
quences. Giovanni  Targioni  Tozetti  recommends  the  extirpa- 
tion of  the  ovaries  as  a  last  resource,  when  all  other  curative 
means  have  failed.  ('  Prima  raccolta  di  osservazioni  mediche,' 
Firenze,  1752,  p.  78.) 


182  OVARIOTOMY  ADVOCATED  BY 

Ulric  Peyer  ('Acta  Helvetica,'  t.  t.  Basil,  1751,  app.  1), 
Theden  ('  Nova  acta,  nat.  curios.,'  torn.  v.  p.  289),  and  Dela- 
porte  ('Memoires  de  l'Academie  Eoyale  de  Chirurgie,'  1833, 
p.  757)  recommend  the  extirpation  of  ovarian  tumours ;  and 
Morvand,  the  Secretary  to  the  Academy,  prophesies  the  ulti- 
mate triumph  of  this  operation  with  the  words :  '  Modern  sur- 
gery is  capable  of  great  achievements  ;  unlimited  roads  ought 
to  be  opened  to  her  goal— to  cure.' 

Antony  de  Haen  ('  Kation.  Medend.,'  part  iv.  cap.  5,  §  2) 
and  Morgagni  were  opposed  to  the  operation,  which  W.  Hunter 
and  Van  Swieten  ('  Commentaries  in  H.  Boerhave's  Aphor.,' 
1770,  torn.  iv.  §  1223)  justify  in  extreme  cases. 

Dr.  William  Hunter,  in  a  paper  '  On  Cellular  Tissue,'  pub- 
lished in  1762,  in  the  second  volume  of  the  '  Medical  Observat- 
ions and  Inquiries,'  after  stating  that  the  trocar  is  almost  the 
only  palliation  in  the  treatment  of  ovarian  dropsy,  says :  '  It 
has  been  proposed  by  modern  surgeons,  deservedly  of  the  first 
reputation,  to  attempt  a  radical  cure  by  incision  or  suppura- 
tion, or  by  excision  of  the  cyst.'  In  support  of  his  opinion, 
6  that  excision  can  hardly  be  attempted,'  having  pointed  out 
difficulties  during  the  operation,  and  dangers  following  it, 
he  concludes  with  the  following  words,  which  foreshadow  some 
of  the  modifications  in  the  operation,  by  which  ovariotomy,  once 
stigmatised,  has  become  one  of  the  most  brilliant  triumphs 
of  modern  surgery :  '  If  it  be  proposed,  indeed,  to  make  such  a 
wound  in  the  belly,  as  will  admit  tivo  fingers  or  so,  and  then 
tap  the  bag  and  draw  it  out,  so  as  to  bring  its  root  or  peduncle 
close  to  the  wound  of  the  belly,  that  the  surgeon  may  cut  it 
without  introducing  his  hand,  surely  in  a  case  otherwise  so 
desperate  it  might  be  advisable  to  do  it,  could  we  beforehand 
know  that  the  circumstances  would  admit  such  treatment.' 
(Op.  cit.  p.  45.) 

In  a  lecture  delivered  in  1785,  John  Hunter  says :  '  I  cannot 
see  any  reason  why,  when  the  disease  can  be  ascertained  in  an 
early  stage,  we  should  not  make  an  opening  into  the  abdomen 
and  extract  the  cyst  itself.  Why  should  not  a  woman  suffer 
spaying,  without  danger,  as  well  as  other  animals  do  ?  The 
merely  making  an  opening  into  the  abdomen  is  not  highly 
dangerous.     In  a  sound  constitution,  perhaps,  a  wound  merely 


THE  HUNTERS  AND  OTHERS  183 

into  the  abdomen  would  never  be  followed  by  death  in  con- 
sequence of  it.' 

Not  many  years  later,  ovariotomy  found  an  enthusiastic 
advocate  in  Chambon  ('  Maladies  des  femmes.  Maladies  chro- 
niques  a  la  cessation  des  regies,'  chap,  xxxix.  '  De  l'extirpation 
des  ovaires,'  Paris,  1798).  Adhesions,  he  says,  do  not  generally 
render  ovariotomy  impossible.  They  are  mostly  found  between 
the  tumour  and  the  peritoneum,  the  broad  ligament,  the  Fallo- 
pian tubes  and  their  fringes,  sometimes  the  omentum  and 
the  intestines.  It  is  not  always  possible  to  determine  the 
extent,  and  the  nature  of  the  existing  adhesions  beforehand, 
when  the  tumour  is  movable.  When  the  tumour  is  free,  dif- 
ficulties in  the  operation  and  serious  accidents  will  seldom  be 
met  with,  provided  the  patient  is  not  suffering  from  any  dis- 
crasia  or  is  not  much  exhausted,  and  then  the  operation  ought 
not  to  be  performed.  Adhesions  with  the  omentum  seldom 
interfere  with  the  mobility  of  the  tumour,  in  which  case  their 
diagnosis  is  difficult.  The  adherent  border  of  the  omentum  may 
be  removed  without  danger.  Abnormal  connections  between 
the  tumour  and  intestines  will  not  contra- indicate  the  operation, 
unless  there  is  a  high  degree  of  inflammation,  by  which  the 
adhesion  has  been  contracted.  In  such  a  case,  the  tumour  will 
be  found  firmly  connected  with  the  intestines,  and  it  will  be 
better  to  abstain  from  the  operation.  Such  adhesions  are  not 
only  very  extensive,  but  also  very  intricate,  the  tumour  and 
the  neighbouring  intestine  forming  almost  one  mass.  If  it  be 
impossible  to  remove  the  diseased  parts,  either  a  portion  of 
the  tumour  must  be  left  behind,  and  a  protracted  and  danger- 
ous suppuration  would  be  the  consequence ;  or  a  portion  of  the 
adherent  viscus  must  be  removed,  which  would  place  the  life 
of  the  patient  in  jeopardy.  He  thought  that  all  the  different 
varieties  of  ovarian  degeneration  might  be  extirpated,  provided 
none  of  the  above  contra-indications  were  present.  The  same 
rules  apply  also  to  the  dropsy  of  the  tubes.  There  are  ovarian 
tumours  which,  after  having  attained  a  certain  size,  will  remain 
stationary.  This  will  be  observed  sometimes  in  scirrhus.  Such 
cases  should  not  be  interfered  with.  He  concludes  with  the 
words,  '  I  am  convinced  that  a  time  will  come  when  this  opera- 
tion will  be  considered  practicable  in  more  cases  than  I  have 


184  MCDOWELL   OF   KENTUCKY 

enumerated,  and  that  the  objections  against  its  performance 
will  cease.' 

John  Bell  never  performed  ovariotomy,  but  Dr.  Ephraim 
McDowell,  a  Virginian,  practising  in  Kentucky,  had  attended 
Bell's  course  of  lectures  in  Edinburgh,  in  1794.  It  is  said  of 
him  by  his  biographer,  Dr.  Grross,  that  he  was  <  enraptured  by 
the  eloquence  of  his  teacher  ;  and  the  lessons  which  he  imbibed 
were  not  lost  upon  him  after  his  return  to  his  native  country. 
Bell  is  said  to  have  dwelt  with  peculiar  force  and  pathos  upon 
the  hopeless  character  of  ovarian  tumours  when  left  alone,  and 
of  the  practicability  of  removing  them  by  operation.  It  is 
not  improbable  that  the  young  Kentuckian,  while  listening  to 
the  teaching  of  the  ardent  and  enthusiastic  Scotchman,  deter- 
mined in  his  own  mind  to  extirpate  the  ovaries  of  the  first  case 
that  should  present  itself  to  him  after  his  return  to  his  native 
country.  The  subject  had  evidently  made  a  strong  impression 
upon  him,  and  had  frequently  engaged  his  attention  and  re- 
flection. He  had  thoroughly  studied  the  relations  of  the  pelvic 
viscera  in  their  healthy  and  diseased  conditions,  and  felt  fully 
persuaded  of  the  practicability  of  removing  enlarged  ovaries 
by  a  large  incision  through  the  walls  of  the  abdomen.' 

McDowell  returned  to  Kentucky  in  1795,  and  commenced 
practice  at  once ;  but  it  was  not  until  fourteen  years  afterwards 
that  he  was  consulted  (in  1809)  by  a  patient  upon  whom  he 
first  performed  ovariotomy,  and  who  survived  in  good  health 
until  1814,  and  died  after  the  completion  of  her  seventy-eighth 
year. 

No  one  can  dispute  the  validity  of  the  direct  claim  of 
McDowell  as  practically  the  first  successful  ovariotomist.  At  the 
same  time  it  must  be  maintained,  that  the  still  greater  merit 
of  pointing  out  the  absence  of  any  physiological  reasons  against 
the  operation,  the  possibility  of  its  safe  performance  in  the 
human  female,  and  the  class  of  cases  in  which  it  ought  to  be 
admissible,  is  due  to  the  teaching  of  the  Hunters  and  of  John 
Bell.  But  in  this  country,  such  is  the  sacredness  of  human  life, 
even  when  threatened  by  fatal  disease;  so  strong  is  the  conscious- 
ness that  the  introduction  of  innovations  like  ovariotomy  insures 
the  destruction  or  shortening  of  a  certain  number  of  lives 
during  the  tentative  stage  of  the  practice,  that  men  even  of 
the  stamp  of  the  Hunters  and  the  Bells  naturally  shrank  from 


THE   FIRST   TO    COMPLETE   OVARIOTOMY  185 

the  responsibility,  imposed  upon  them  by  their  position  and 
reputation,  of  adopting  and  inaugurating  it  as  a  part  of  legiti- 
mate surgery ;  and  elected  rather,  in  the  modesty  of  their 
greatness — '  stare  decisis  et  non  quieta  movere  ' — to  content 
themselves  by  tending  with  careful  pains  the  last  flickerings 
of  life  in  their  confiding  patients,  and  soothing,  as  best 
they  might,  their  prolonged  sufferings,  than,  as  it  would 
seem  to  them,  proceed  to  the  choice  and  immolation  of  the 
sacrificial  victims  demanded  as  the  inevitable  price  of  the 
safety  of  future  generations,  or  the  aggrandisement  of  their 
own  fame.  And  it  must  be  remembered  that,  at  that  time 
of  day,  the  mortality  from  all  operations  was  much  greater 
than  it  is  now ;  that  the  sick  and  diseased  were  more  passively 
quiescent  under  their  maladies  and  less  tolerant  of  any  surgical 
suggestions,  just  as  we  ourselves  find  to  be  the  case  among  the 
unroused  population  of  an  outlying  agricultural  district ;  that 
they  were  not  buoyed  up,  as  modern  women  are,  by  the  histories 
and  promises  of  painless  extirpations  under  chloroform  or 
methylene ;  and  that,  without  anything  like  mawkish  senti- 
mentalism,  surgeons  themselves  had  to  encounter  the  '  peine 
forte  et  dure '  of  their  suppressed  sympathy,  and  nerve  them- 
selves up  to  the  infliction  of  the  most  deliberate  and  tedious 
eviscerative  vivisection.  The  disease  was  looked  upon  as  a 
mystery,  and  its  ending  in  death  as  a  matter  of  course  ;  and, 
instead  of  being  accompanied,  as  we  now  see  it,  by  fretful 
resistance  and  chafings  to  escape,  it  only  led  to  stolid  endurance 
or  religious  submission ;  and,  on  the  part  of  the  profession,  to 
pity  and  endeavours  to  alleviate  the  inevitable  misery. 

But  McDowell  was  a  free  man,  in  a  new  country,  clear  from 
the  conventional  trammels  of  old-world  practice,  found  his 
patients  in  the  most  favourable  conditions  of  animal  life,  seems 
to  have  had  one  of  those  incomprehensible  runs  of  luck  upon 
which  a  man's  fate  and  reputation  so  often  turn  if  he  has 
the  sagacity  and  energy  to  put  such  fortunate  accidents  to 
good  account,  and  was  happy,  as  those  usually  are  who  can 
afford  or  constrain  themselves  to  wait,  in  finding  suitable 
time,  place,  persons,  and  opportunity  for  working  into  fact  the 
notions  of  his  tutor  Bell.  He  lost  only  the  last  of  his  first 
five  cases  of  ovariotomy,  and  thus,  as  it  were,  established  at 
the   outset   what   until   recently  was   complacently   regarded 


186  ACCOUNT   OF   HIS   FIRST   OPERATION 

as  a  satisfactory  standard  of  mortality  for  so  serious  an 
operation. 

The  details  of  his  first  operation,  as  recorded  by  Dr.  Gross, 
are  interesting  enough  for  repetition,  and  supply  the  best 
testimony  to  his  sagacity,  firmness,  and  caution : — ■ 

'It  was  performed  on  Mrs.  Crawford,  of  Kentucky,  in 
December  1809.  The  tumour  inclined  more  to  one  side  than 
the  other,  and  was  so  large  as  to  induce  her  professional  attend- 
ant to  believe  that  she  was  in  the  last  stage  of  pregnancy. 
She  was  affected  with  pains,  similar  to  those  of  labour,  from 
which  she  could  find  no  relief.  The  wound  was  made  on  the 
left  side  of  the  median  line,  some  distance  from  the  outer  edge 
of  the  straight  muscle,  and  was  nine  inches  in  length.  As 
soon  as  the  incision  was  completed,  the  intestines  rushed  out 
upon  the  table;  and  so  completely  was  the  abdomen  filled 
by  the  tumour  that  they  could  not  be  replaced  during  the 
operation,  which  was  finished  in  twenty-five  minutes.  In 
consequence  of  its  great  bulk,  Dr,  McDowell  was  obliged 
to  puncture  it  before  it  could  be  removed.  He  then  threw  a 
ligature  round  the  Fallopian  tube,  near  the  uterus,  and  cut 
through  the  attachments  of  the  morbid  growth.  The  sac 
weighed  seven  pounds  and  a  half,  and  contained  fifteen  pounds 
of  a  turbid,  gelatinous-looking  substance.  The  edges  of  the 
wound  being  brought  together  by  the  interrupted  suture  and 
adhesive  strips,  the  woman  was  placed  in  bed  and  put  upon 
the  antiphlogistic  regimen.  "  In  five  days,"  says  Dr.  McDowell, 
"  I  visited  her,  and,  much  to  my  astonishment,  found  her 
engaged  in  making  up  her  bed.  I  gave  her  particular  caution 
for  the  future  ;  and  in  twenty-five  days  she  returned  home  in 
good  health,  which  she  continues  to  enjoy." 

6  It  will  not  be  uninteresting  here  to  state  that  Mrs.  Craw- 
ford, at  the  time  of  the  operation  performed  upon  her  by  Dr. 
McDowell,  lived  in  Green  County,  Kentucky,  from  whence  she 
removed,  some  time  afterwards,  to  a  settlement  on  the  Wabash 
Kiver,  in  Indiana,  where  she  died,  March  30,  1841,  in  the  79th 
year  of  her  age.  There  was  no  return  of  her  disease,  and  she 
generally  enjoyed  excellent  health  up  to  the  period  of  her  death. 
She  had  no  issue  after  the  operation.  The  youngest  child,  Mr. 
Thomas  H.  Crawford,  who  has  kindly  communicated  to  me  these 
facts,  was  born  in  1803,  nearly  six  years  before  the  operation.' 


HIS  CHARACTER   AS  A   SURGEON 


187 


Dr.  McDowell  was  a  kind-hearted,  amiable  man,  an  accom- 
plished scholar,  though  no  writer,  indifferent  to  notoriety,  but 
with  an  extensive  reputation.  As  a  surgeon,  he  was  exceed- 
ingly cautious,  calm,  and  firm ;  paying  great  attention  to  the 
details  of  his  operations  and  treatment,  and  selecting  and 
drilling  his  assistants  with  much  care. 

In  person  he  was  nearly  six  feet  in  height,  with  a  florid  com- 


plexion,  and  very  black  eyes.  He  was  of  a  remarkably  happy 
disposition,  and  rather  inclined  to  corpulency.  Up  to  the  time 
of  his  last  sickness,  he  was  one  of  the  most  active  men  in 
Kentucky.  Dr.  McDowell  remained  faithful  to  his  profession 
until  the  last  moments  of  his  life.  He  died,  literally,  in 
harness.  The  portrait  above  is  copied  from  a  photograph  taken 
from  an  oil  painting  now  in  possession  of  the  family,  and 
sent  to  me  by  Dr.  Jackson,  of  Danville,  Kentucky,  who 
informed  me  that  the  painting  was  by  Jewett,  taken  when 
the  sitter  was  in  his  fifty-sixth  year,  and  was  deemed  by  his 
family  an  excellent  likeness. 


188        OPERATIONS   WRONGLY   DESCRIBED   AS   OVARIOTOMY 

McDowell  was  buried  in  the  cemetery  near  the  scene  of  his 
life-work,  and  there  rested  tranquilly,  his  memory  respected  and 
his  good  deeds  bearing  their  fruit,  till  in  1879  it  was  deemed  a 
fitting  thing  to  perpetuate  the  world-wide  association  of  his 
name  with  ovariotomy  by  a  granite  obelisk  and  some  character- 
istic inscriptions. 

In  1808,  one  year  before  Dr  McDowell's  first  operation, 
D'Escher  ('  Considerations  medico-chirurgicales  sur  l'hydropisie 
enkystee  desovaires.'  These :  Montpellier,  1808  )  suggested  the 
removal  of  diseased  ovaries  through  an  incision  along  the  ex- 
ternal border  of  the  rectus  muscle.  Existing  adhesions  should 
be  detached  with  the  fingers,  or,  if  necessary,  with  a  bistoury ; 
the  tumour  extracted  and  excised  after  the  application  of  a 
ligature  around  the  pedicle.  The  ends  of  the  ligature  were  to 
be  brought  out  by  the  wound,  the  edges  of  which  were  kept 
in  close  opposition  by  lateral  pads  and  a  bandage  around  the 
body. 

McDowell's  case  has  long  been  considered  the  first  case  of 
ovariotomy  on  record ;  for  the  operation  of  L'Aumonier  of 
Rouen,  in  1776 — which  had  been  referred  to  as  one  of  ovari- 
otomy, and  which  even  Dr.  Atlee,  in  his  table  (published  in 
1851),  enumerated  as  the  first  operation  of  ovariotomy — was  in 
a  case  of  pelvic  abscess,  which  he  opened  by  an  incision  through 
the  wall  of  the  abdomen  above  Poupart's  ligament,  six  or  seven 
weeks  after  parturition.  He  seems  also  to  have  separated  the 
fimbriae  of  the  Fallopian  tube  from  the  sac  of  the  abscess,  and 
to  have  removed  the  ovary  without  any  necessity,  and  without 
any  idea  of  ovariotomy.  His  case  may  be  found  recorded  in 
the  '  Histoire  de  la  Societe  royale  de  la  Medecine,'  1782,  torn.  v. 
p.  298. 

Another  case,  included  in  some  of  the  tables  of  ovariotomy 
by  Professor  Dzondi,  is  one  in  which  a  pelvic  tumour  was  cured 
by  drawing  out  a  cyst  through  an  incision  in  the  abdominal 
wall  of  a  boy  twelve  years  old. 

Atlee,  however,  communicated  (in  the  '  American  Journal  of 
Medical  Sciences,'  vol.  xvii.  1849,  p.  534)  a  case  which  claims 
the  priority  to  that  of  McDowell  by  more  than  a  century.  It 
is  the  case  of  Dr.  Robert  Houstoun,  which  may  be  found  under 
the  head,  *  A  dropsy  of  the  left  ovary  of  a  woman,  aged  fifty- 
three  years,  cured  by  a  large  incision  made  in  the  side  of  the 


OVARIOTOMY   ATTEMPTED   BY   HOUSTOUN  189 

abdomen,'  in  the  *  Philosophical  Transactions  '  (from  the  year 
1719  to  1733),  abridged  and  disposed  under  general  heads, 
vol.  vii.  p.  541  (London,  1734).  From  this  case  it  will  appear 
that  ovariotomy  originated  with  British  surgery,  on  British 
ground,  inasmuch  as  though  the  operation  was  not  one  of 
complete  excision  of  the  tumour,  it  was  planned  with  that 
intention. 

Dr.   Kobert  Houstoun   operated,   in  August    1701,   on   a 
Mrs.  Margaret  Miller,  near  Glasgow,  who  since  her  last  con- 
finement, thirteen  years  before,  when  twenty-three  years   of 
age,  suffered  from  ovarian  dropsy.     The  tumour  had  grown  to 
a  monstrous  bulk ;  she  was  much  wasted,  had  great  difficulty 
in  breathing,  want  of  appetite  and  sleep,  and  bed-sores  from 
long  confinement.     This  case  is  in  many  respects  a  very  curious 
one,  and  the  operator's  own  words  are  worthy  of  record.      He 
says :  '  After  having   obtained  the   patient's  consent  that,  in 
order  effectually  to  relieve  her,  I  must  lay  open  a  great  part 
of  her  belly,  and  remove  the  cause  of  all  that  swelling.  .  *  .  I 
prepared  without  loss  of  time  what  the  place  would  allow,  and 
with  an  imposthume  lancet  laid  open  about  an  inch  ;  but  find- 
ing nothing  issue*  I  enlarged  it  two  inches ;  but  even  then 
nothing  came  forward  but  a  little  thin  yellowish  serum,  so  I 
ventured  to  lay  open  two  inches  more.     I  was  not  a  little 
startled,  after  so  large  an  aperture,  to  find  it  stopped  only  by  a 
glutinous  substance.     All  my  difficulty  was  to  remove  it.      I 
tried  my  probe — I  endeavoured  with  my  fingers,  but  all  was  in 
vain ;  it  was  so  slippery  that  it  eluded  every  touch  and  the 
strongest  hold  that  I  could  take.     I  wanted  in  this  place  almost 
everything  necessary,  but  bethought  myself  of  a   very  odd  in- 
strument, but  as  good  as  the  best,  because  it  answered  the  end 
proposed.     I  took  a  strong  fir-splinter,  wrapped  some  loose  lint 
about  the  end  of  it,  and  thrust  it  into  the  wound  ;    and  by 
turning  and  winding  it,  I  drew  out  about  two  yards  in  length  of 
a  substance  thicker  than  any  jelly,  or  rather  like  glue  that  is 
fresh  made  and  hung  out  to  dry ;  the  breadth  of  it  was  above 
ten  inches.     This   was  followed  by  nine  full  quarts  of  such 
matter  as  I  have  met  with  in  steatomatous  and  atheromatous 
tumours,  with  several  hydatids  of  various   sizes  containing  a 
yellow  serum,  the  least  of  them  bigger  than  an  orange,  with 
several  large  pieces  of  membrane,  which  seemed  to  be  parts  of 


190  CASES   OF   OVARIOTOMY 

the  distended  ovary.  Then  I  squeezed  out  all  I  could,  and 
stitched  up  the  wound  in  three  places,  almost  equidistant.  The 
lower  part  of  the  wound  was  kept  open  by  a  small  tent.  Some 
serosity  discharged  from  it  for  four  or  five  days.  The  wound 
was  covered  in  its  whole  length  with  a  pledget  spread  with 
some  home-made  balsam,  over  that  several  compresses  dipped 
in  warm  brandy,  then  several  towels ;  all  these  dressings  were 
fastened  by  swathing  her  round  the  body.  An  anodyne  was 
given  several  times  a  day.  The  next  morning  the  patient  was 
found  much  refreshed  by  a  good  night's  rest,  the  first  she 
enjoyed  for  three  months  past.  After  three  weeks  she  was  able 
to  sit  outdoors,  wrapped  up  in  blankets,  superintending  her 
farm-labourers.  She  recovered,  and  lived  in  perfect  health 
from  that  time  till  October  1717,  when  she  died  after  ten  days' 
illness.' 

Although  this  isolated  case  of  Dr.  Houstoun  undoubtedly 
strengthens  the  claim  of  British  surgery  to  the  honour  of 
originally  practising  ovariotomy,  it  will  hardly  deprive  Dr. 
McDowell  of  his  undeniable  merit  of  having  been  the  first  who, 
guided  by  scientific  principles,  enriched  modern  surgery  with 
the  operation.  He  followed  up  his  first  case  by  others.  He 
performed  the  operation  thirteen  times  altogether  between  1809 
and  his  death  in  1830.  The  precise  number  of  deaths  cannot 
be  ascertained,  but  of  eight  cures  there  can  be  no  doubt. 
McDowell's  successes  were  followed  up  by  other  American  sur- 
geons. In  1822,  Mr.  Smith,  of  Connecticut,  performed  a  suc- 
cessful operation.  He  removed  a  cyst  containing  six  pints  of 
fluid,  through  an  incision  five  inches  long.  He  broke  dowu 
extensive  adhesions  between  the  tumour  and  the  abdominal 
wall  and  the  omentum.  The  wound  was  united  by  means  of 
adhesive  plaster  and  roller.  No  unfavourable  symptom  occurred 
until  the  separation  of  the  ligature,  when  an  abscess  formed, 
which  had  to  be  opened.  The  patient,  twenty- three  years  of 
age,  was  able  to  walk  after  three  weeks,  and  speedily  recovered. 
(Case  of  ovarian  dropsy  successfully  removed  by  a  surgical 
operation,  'Edinburgh  Medical  and  Surgical  Journal,'  1822; 
and  'American  Medical  Eecorder,'  Philadelphia,  vol.  v.  1822, 
No.  7.) 

In  another  case  Smith  was  unable  to  complete  the  operation 
on  account  of  extensive  adhesions.     He  emptied  the  cyst,  and 


BY  EARLY  OPERATORS  191 

the  patient  recovered.  But  the  cyst  filled  again.  ('  Med.  and 
Surg.  Memoirs,'  p.  231.) 

In  1823,  Gr.  Smith  removed  an  ovarian  tumour  from  a  negro 
woman,  through  an  incision  extending  from  the  umbilicus  to 
the  os  pubis,  after  having  previously  emptied  the  contents  of 
the  cyst.  The  peduncle  was  secured  by  a  ligature.  The  patient 
recovered  within  twenty-five  days.  ('  North  American  Med. 
and  Surg.  Journal,'  January  1826.) 

Lizars,  of  Edinburgh,  was  the  first  to  attempt  ovariotomy  in 
this  country.  He  performed  two  operations  in  1825,  of  which 
the  first  was  successful,  the  second  fatal  in  fifty-six  hours.  He 
opened  the  abdomen  on  two  other  occasions,  but  only  to  prove 
errors  of  diagnosis.     Both  patients  recovered. 

The  first  attempt  to  perform  ovariotomy  in  London  was  made 
in  1827,  by  Dr.  Granville,  who  operated  in  two  cases.  In  one 
the  operation  was  abandoned  on  account  of  the  extent  of  the 
adhesions ;  the  woman  recovered.  In  the  other  case  a  fibrous 
tumour  of  the  uterus,  weighing  eight  pounds,  was  removed ; 
but  the  patient  died  on  the  third  day. 

The  ill-success  of  Mr.  Lizars  and  Dr.  Granville,  who  both 
operated  by  the  long  incision,  brought  discredit  upon  the 
operation  ;  and  it  was  not  until  1836,  nine  years  after  Dr.  Gran- 
ville's failures,  that  a  provincial  surgeon,  Dr.  Jeaffreson,  of 
Framlingham,  acted  upon  the  suggestion  of  William  Hunter, 
and  performed  ovariotomy  by  the  small  incision  for  the  first 
time  in  Great  Britain.  A  bilocular  cyst  was  removed  through 
an  opening  only  an  inch  and  a  half  long.  The  patient  was 
alive  in  1859,  was  fifty-six  years  of  age,  and  had  given  birth  to 
one  boy  and  three  girls  after  the  operation. 

In  the  same  year  (1836),  another  provincial  surgeon,  Mr. 
King,  of  Saxmundham,  successfully  removed  an  ovarian  cyst 
through  an  incision  only  three  inches  long ;  and  Mr.  West,  of 
Tonbridge,  also  had  a  successful  case,  the  incision  being  only 
two  inches  long.  In  1838,  Mr.  Crisp,  of  Harleston,  in  Suffolk, 
removed  a  multilocular  cyst  through  an  incision  only  one  inch 
long.  The  patient  lived  fifteen  years  after  the  operation,  and 
enjoyed  good  health. 

In  1839,  Mr.  West,  of  Tonbridge,  had  a  second  successful 
case  ;  a  single  cyst,  which  contained  twenty-two  pints  of  fluid, 
having  been  removed  by  the  short  incision.     Mr.  West  also 


192  OVARIOTOMY  FORTY  YEARS  AGO 

had  an  unsuccessful  case  of  completed  ovariotomy,  and  one  in 
which  the  adhesions  prevented  the  completion  of  the  operation. 
In  the  same  year  the  first  attempt  to  perform  ovariotomy  in  a 
London  hospital,  of  which  I  have  been  able  to  find  any  record, 
was  made  at  Guy's,  by  Mr.  Morgan  ;  a  small  incision  was  made, 
adhesions  were  found,  the  tumour  was  not  removed,  and  the 
patient  died  in  twenty-four  hours. 

In  1840,  Mr.  Benjamin  Phillips  operated  at  the  Marylebone 
Infirmary,  and  completed  the  operation  for  the  first  time  in 
London  ;  but  the  result  was  unsuccessful. 

In  1842,  Dr.  Clay,  of  Manchester,  commenced  his  series  of 
operations,  performing  ovariotomy  four  times,  and  in  three  out 
of  the  four  with  success.  In  1843,  he  also  operated  four  times, 
twice  successfully.  In  1843,  Mr.  Aston  Key  removed  both 
ovaries  from  a  patient  in  Gruy's  Hospital.  His  incision 
extended  from  the  ensiform  cartilage  to  the  pubes,  and  death 
followed  on  the  fourth  day.  Later  in  the  same  year,  Mr. 
Bransby  Cooper  operated  in  the  same  hospital  by  the  long 
incision,  and  removed  a  large  multilocular  cyst,  but  the  patient 
died  on  the  seventh  day. 

So  that  forty  years  ago,  although  ovariotomy  had  been 
performed  with  very  qualified  success  in  one  case  in  Scotland, 
and  in  at  least  ten  cases  with  complete  success  by  surgeons  in 
our  own  provinces,  it  had  never  been  performed  successfully  in 
London.  It  was  the  good  fortune  of  Mr.  Walne  to  perform  the 
first  successful  operation  in  London,  in  November  1842;  and 
he  had  two  other  successful  cases  in  May  and  September  1843. 
In  that  year,  and  in  1844,  Dr.  Frederic  Bird  had  three,  and 
Mr.  Lane  two  successful  cases.  Mr.  Lane's  first  patient  was 
still  alive  in  1867,  and  had  seven  children.  In  1843  and 
1845,  Mr.  Southam,  of  Salford,  and  in  1845,  Mr.  Dickson,  of 
Shrewsbury,  published  successful  cases.  In  1846,  Mr.  H.  E. 
Burd  had  a  case  which  is  published  in  the  30th  and  32nd 
volumes  of  the  '  Medico-Chirurgical  Transactions.'  The  patient 
recovered,  and  had  a  child  two  years  after  the  operation. 

In  the  same  year  Mr.  Solly  took  advantage  of  an  unsuc- 
cessful case  which  occurred  in  his  practice  in  St.  Thomas's 
Hospital,  to  teach  his  pupils  and  professional  brethren  that 
retraction  of  the  pedicle  behind  the  ligature  is  very  likely  to 
occur  and  to  lead   to  fatal  haemorrhage,  unless  prevented  by 


SUCCESSFUL    CASE    BY    MR.    CESAR    HAWKINS  193 

great  care.  His  clinical  lecture,  published  in  the  'Medical 
Gazette  '  in  1846,  contains  a  masterly  review  of  the  arguments 
for  and  against  the  operation,  which  must  have  had  considerable 
effect  upon  the  mind  of  the  profession  at  the  time. 

The  year  1846  is  also  noteworthy  in  the  history  of  ovari- 
otomy. In  the  month  of  September  Mr.  Csesar  Hawkins  per- 
formed the  operation  for  the  first  time  successfully  in  any 
London  hospital.  Even  now,  after  the  long  interval  of  five-and- 
thirty  years,  with  all  our  accumulated  experience  obscuring  the 
individuality  of  its  history,  it  is  not  only  interesting  but  useful 
to  look  back  upon  this  initial  glimpse  of  success  and  reopen 
the  pages  of  the  clinical  lecture  which  was  its  record  and 
commentary.  The  cautious  deliberation  with  which  the  opera- 
tion was  decided  upon,  the  attention  to  all  the  maxims  of 
scientific  surgery  which  went  with  every  step  of  the  work,  the 
skill  and  precaution  with  which  it  was  executed,  and  the 
judicious  after-treatment  of  the  patient,  all  offered  an  example 
for  imitation  as  much  as  the  lecture  furnished  a  lesson  for 
study  in  the  exactitude  of  its  details,  the  lucidity  of  its  exposi- 
tions, and  the  judiciousness  of  its  advice.  It  was  a  simple  case 
admirably  recorded,  standing  out  in  our  literature  as  a  sort  of 
monumental  standard  by  which  we  can  measure  ourselves,  and 
which  forces  us  to  moderate  our  exultation  in  what  has  been 
accomplished  by  the  proof  that  in  the  last  generation  there 
were  men  endowed  with  all  the  qualities  of  skill  and  wisdom 
which  would  have  enabled  them  to  do  still  more  if  their  ener- 
gies had  not  been  diverted  to  other  objects.  Mr.  Hawkins  did 
not  repeat  the  operation,  and  his  example  was  not  much  fol- 
lowed by  others  for  several  years ;  Dr.  F.  Bird  and  Mr.  Lane 
being  the  only  operators  in  London,  except  Dr.  Protheroe 
Smith,  who  had  a  successful  case,  although  Dr.  Clay  continued 
his  operations  at  Manchester,  and  successful  cases  were  recorded 
by  Dr.  Elkington,  of  Birmingham,  and  by  Mr.  Crouch  in  1849, 
and  by  Mr.  Cornish,  of  Taunton,  and  Mr.  Day,  of  Walsall,  in 
1850. 

In  1850,  Mr.  Duffin  inaugurated  a  new  era  in  ovariotomy, 
by  pointing  out  the  danger  of  leaving  the  tied  end  of  the 
pedicle  to  decompose  within  the  peritoneal  cavity,  and  by  in- 
sisting upon  the  importance  of  keeping  the  strangulated  stump 
outside.     He  acted   up  to  this  principle   in  a  ease  which  was 

0 


194  MR.  duffin's  treatment  of  the  pedicle 

published  in  the  thirty-fourth  volume  of  the  '  Medico-Chirar- 
gical  Transactions.' 

He  was  brought  to  the  resolution  of  adopting  this  extra- 
peritoneal treatment  of  the  pedicle  not  by  any  accidental 
necessity,  but  by  '  reflecting  on  the  two  great  causes  of  death 
in  unsuccessful  cases  of  ovariotomy,  and  the  three  several 
periods  at  which  a  fatal  termination  may  occur,  viz.  from  shock, 
from  peritonitis,  and  at  a  later  period,  caused,  as  it  appears,  on 
separation  of  the  slough,  by  putrefactive  decomposition  within 
the  peritoneal  cavity.'  It  suggested  itself  to  him  that  '  this 
latter  consequence,  as  well  as  the  irritation  caused  by  the  liga- 
ture in  the  abdomen,  might  be  obviated  by  keeping  the  tied 
portion  completely  out  of  the  cavity.'  He  determined,  there- 
fore, to  do  so  by  fixing  the  tied  end  of  the  pedicle  outside  the 
edges  of  the  wound  ;  but  as  he  found  the  length  of  stump  that 
he  had  to  deal  with  not  sufficient  for  this,  he  was  obliged  to 
content  himself  by  stitching  the  cut  extremity  and  ligature  in 
the  wound  so  as  to  prevent  them  receding  into  the  pelvis,  and 
to  retain  them  in  that  situation  till  the  ligature  should  come 
away.  It  answered  completely.  The  wound  was  entirely  healed 
and  the  patient  well  on  the  twenty-second  day.  The  only  objec- 
tion was  the  dragging  of  the  abdominal  wall  towards  the  spine  ; 
but  no  adhesions  formed,  and  the  abdomen  soon  returned  to  its 
natural  form. 

Whatever  may  be  our  opinions  and  practice  at  the  present 
time,  and  whatever  views  we  may  hold  upon  the  question, 
whether  this  extra-peritoneal  treatment  of  the  pedicle  has 
advanced  or  retarded  the  success  of  the  operation,  Air.  Duffin's 
arguments  undeniably  led  to  great  changes  and  results : — to 
the  use  of  the  clamp  and  to  all  the  modifications  of  treatment 
attendant  upon  it,  and  ultimately  to  researches  as  to  the  phy- 
siological and  pathological  phenomena  of  ligatured  stumps 
within  the  peritoneal  cavity,  and  to  the  study  of  the  important 
subject  of  drainage  by  Kceberle  and  others. 

Some  Grerman  writers  think  that  the  credit  here  given  to 
Mr.  Duffin  should  be  awarded  to  Stilling,  because  in  1841  he 
published  a  case  in  which  he  sewed  the  pedicle  with  a  part  of 
the  cyst  between  the  lips  of  the  wound  in  the  abdominal  wall, 
after  he  had  stopped  the  bleeding  from  some  of  the  vessels  by 
torsion,  and  from  others  by  ligature  and  the  cautery.     But  this 


THE    SAMARITAN    HOSPITAL  195 

can  hardly  be  called  a  truly  extra-peritoneal  treatment.  It  is 
more  like  what  Langenbeck  in  1851,  and  Storer  in  1867, 
described  as  '  Einnahen,'  or  '  pocketing  the  pedicle.'  It  was  after 
Duffin  that  Stilling  adopted  a  more  complete  extra-peritoneal 
method  by  transfixing  the  pedicle  with  a  needle,  which,  after  the 
pedicle  was  tied,  fixed  it  outside  the  closed  wound.  Martin 
afterwards  thus  far  varied  Stilling's  method,  sewing  only  the 
peritoneal  coat  of  the  pedicle,  instead  of  the  base  of  the  tumour, 
to  the  abdominal  wall. 

I  began  work  in  London  in  1853,  and  in  the  following  year 
joined  what  is  now  called  the  Samaritan  Hospital.  Dr.  Savage, 
who  is  at  present  senior  consulting  physician,  is  the  only  one  of 
the  acting  staff  who  was  then  connected  with  it.  We  had  at 
the  beginning  only  a  small  house  in  Orchard  Street,  which  was 
pulled  down  several  years  ago.  On  the  ground  floor  were  an 
office  and  a  waiting-room,  and  a  dispensary  downstairs ;  on  the 
first  floor  the  patients  mustered  in  the  front  room  and  were 
attended  to  in  the  back.  On  the  second  floor  there  was  a  room 
for  the  matron,  and  another  for  a  resident  house  surgeon,  whose 
chief  occupation  was  in  bandaging  the  ulcerated  legs  of  a  crowd 
of  out-patients.  On  the  third  floor  there  were  attics,  one  of 
which  was  occasionally  made  use  of  for  an  in-patient.  At  this 
time  I  did  nothing  but  out-patient  work,  and  in  January  1855 
went  off  to  the  Crimea.  But  in  the  April  before  I  had  made  my 
first  acquaintance  with  ovariotomy.  Baker  Brown  invited  me 
to  see  him  operate,  and  I  went  with  Mr.  Nunn  and  assisted  him. 
It  was  his  ninth  case,  a  dermoid  cyst  with  adhesions,  which 
made  the  proceedings  long  and  troublesome.  Nine  days  after 
the  patient  died  of  what  we  can  now  recognize  as  septicaemia. 
This  so  influenced  Brown  that  he  only  did  one,  more  case,  and 
that  unsuccessfully,  during  the  next  four  years  and  a  half, 
saying  that  '  it  was  of  no  use,  peritonitis  would  always  beat 
one.'  I  was  not  favourably  impressed,  but  had  learnt  how 
some  of  the  great  difficulties  might  be  overcome  so  far  as  the 
operation  itself  was  concerned.  Away  from  England,  in  all  the 
excitement  of  war-surgery,  of  course  the  subject  was  at  rest. 
But  after  my  return  in  1856  I  resumed  out-patient  work  in 
Orchard  Street.  Snow  Beck,  G-raily  Hewitt,  and  Priestley  had 
joined  the  staff,  so  had  Routh  and  Wright,  and  we  began  to  hope 
for  something  more  than  dispensary  practice.     By  arrangement 

o  2 


196  MY   FIRST   OVARIOTOMY    IN    1858 

with  the  matron  a  bed  could  every  now  and  then  be  obtained 
in  an  attic.  Snow  Beck  set  the  example  and  operated  on  a 
case  of  vesico-vaginal  fistula  with  the  cautery  and  cured  it. 
We  did  not  often  see  cases  of  ovarian  disease  at  that  time,  but 
they  did  appear  occasionally.  In  one  case  I  had  proposed  to 
attempt  ovariotomy,  but  it  was  decided  that  a  trial  should  be 
given  to  the  treatment  by  injection  of  iodine.  As  I  have  said, 
Brown  had  given  up  the  operation  ;  very  few  others  were  attempt- 
ing it,  and  most  men  were  lapsing  into  the  old  state  of  indif- 
ference, if  they  were  not  loudly  protesting  against  it.  During 
the  autumn  of  1857  a  young  woman  was  under  treatment  for 
what  appeared  to  be  an  ovarian  tumour  on  the  left  side. 
Various  opinions  were  confidently  expressed  that  this  could  not 
be  an  ovarian  tumour,  because  intestines  could  be  felt  in  front 
of  it.     But  I  determined  to  see  what  it  was,  and  in  December 

1857,  twenty-four  years  ago,  I  prepared  for  my  first  ovariotomy. 
Keflecting  upon  all  the  ways  and  forms  of  using  the  ligature,  I 
had  resolved  to  use  the  ecraseur  for  the  division  of  the  pedicle, 
as  was  done  some  months  after  the  publication  of  my  suggestion 
by  Dr.  John  L.  Atlee,  of  Lancaster,  Pa.  We  cleared  out  the 
waiting-room,  got  a  bed  there,  and  secured  a  nurse.  Quite  a 
crowd  of  visitors  came.  As  soon  as  I  opened  the  peritoneum, 
and  it  was  proved  beyond  all  doubt  that  the  tumour  was  behind 
the  intestines,  I  was  induced  very  unwillingly  to  close  the 
wound  and  do  nothing  more.  The  patient  recovered  without 
any  bad  symptom,  but  died  four  months  afterwards  in  St. 
Bartholomew's  Hospital,  when  it  was  found  that  it  was  a 
tumour  of  the  left  ovary,  which  might  have  been  removed 
quite  easily.  This  was  not  encouraging  for  a  beginner,  but  it 
attracted  the  notice  of  Mr.  Bullen,  of  the  Lambeth  Workhouse, 
and  he  offered  me  a  patient  then  in  his  infirmary  who  had  been 
tapped  three  times  in  Guy's  Hospital  and  four  times  in  the 
Lambeth  Workhouse,  and  had  had  iodine  injected.  As  she 
was  willing  to  face  any  risk,  I  did  ovariotomy  for  her  in  February 

1858.  The  pedicle  was  treated  by  whipcord  ligature,  the  ends 
hanging  out  at  the  lower  angle  of  the  wound  after  the  fashion 
of  Clay,  Bird,  Brown,  and  the  earlier  ovariotomists.  At  that 
time  we  had  a  house-surgeon,  Mr.  Cooke,  afterwards  of  Clovelly, 
and  greatly  owing  to  his  constant  care  the  poor  girl  recovered. 
She  became  a  nurse  in  the  hospital,  went  into  service,  then 


MY    FOURTH    CASE  197 

emigrated,  and  I  heard  of  her  several  years  afterwards,  in  1868, 
married  to  the  German  overlooker  of  a  large  estate  in  Queens- 
land, whose  salary  was  240£.  a  year.  Had  ovariotomy  not  been 
performed  she  must  have  died  in  1858  a  pauper  in  a  work- 
house. 

Between  this  first  case,  in  February  1858,  and  the  second 
in  August  of  the  same  year,  we  had  left  the  old  house  and 
removed  to  that  in  Seymour  Street,  where  the  hospital  now  is, 
and  the  second  operation  was  done  in  one  of  the  rooms  in  which 
I  have  since  completed  my  long  series  of  408  hospital  cases. 

The  third  case  was  in  the  following  November,  and  happily 
all  the  three  women  recovered.  Had  they  died,  such  was  the 
state  of  professional  opinion  at  that  time,  the  progress  of  ovari- 
otomy might  have  been  sadly  retarded,  if  not  stopped. 

I  lost  my  fourth  ovariotomy  without  being  able  to  account 
for  the  death.  It  was  the  first  post-mortem  I  had  occasion  to 
make,  and,  though  not  knowing  exactly  what  to  expect,  the 
state  of  the  inner  surface  of  the  wound  was  far  from  satisfactory. 
Dr.  Aitken  assisted  me,  and  he  found  that  the  hare-lip  pins 
which  I  then  used  as  sutures  were  bare  on  the  inner  aspect  of 
the  abdominal  wall,  the  cut  edges  of  the  peritoneum  were  re- 
tracted, and  a  portion  of  intestine  was  in  contact  with  the  wound, 
the  impress  of  which  was  obvious  on  the  surface  of  the  gut. 
Some  coagula  of  blood  and  an  abundant  consistent  lymph 
exudation  upon  the  peritoneal  surface  of  the  intestine  corre- 
sponded with  the  edges  of  the  incision  and  the  surface  of  the 
wound.  Recent  lymph  glued  the  opposing  surfaces  of  the 
intestines  to  each  other.  I  saw  at  once  how  much  better  it 
might  have  been  if  the  peritoneal  edges  had  been  brought 
accurately  together,  and  thought  of  doing  this  in  my  next 
case.  But  I  found  instructions  in  text-books  and  treatises 
carefully  to  avoid  the  peritoneum.  These  doctrines  were  at 
variance  with  the  facts  before  my  eyes.  Physiological  princi- 
ples had  been  overlooked.  I  did  not  question  them,  but  now 
that  an  important  practical  question  was  raised  which  bore  dis- 
tinctly upon  the  failure  of  my  operation,  I  determined  to  put 
to  the  test.  I  made  experiments  upon  animals  for  which 
I  have  been  vilified,  but  for  which  I  do  not  reproach  myself. 
The  preparations  which  I  procured  from  these  creatures  are  still 
preserved  in  the  Museum  of  the  Royal  College  of  Surgeons. 


198     USEFUL  RESULTS  OF  EXPERIMENTS  ON  ANIMALS 

They  corroborate  what  was  known  before,  that  abdominal 
wounds  well  adjusted  unite  readily.  This  was  not  what  I 
wanted.  They  proved  more,  and  were  the  visible,  standing 
evidence  which  I  did  want,  that  though  the  other  tissues 
might  be  brought  together,  if  the  cut  edges  of  the  peritoneum 
were  left  free,  they  retracted,  direct  union  did  not  take  place, 
and  secondary  evil  consequences  resulted.  In  the  specimen 
where  the  divided  edges  or  rather  surfaces  of  peritoneum  have 
been  pressed  together,  the  smooth  serous  inner  coat  of  the 
abdominal  wall  is  perfectly  restored.  The  stitches  on  the 
inside  cannot  be  seen  though  plainly  visible  on  the  skin,  and 
there  is  no  adhesion  of  intestine  or  omentum.  But  in  other 
specimens,  where  the  peritoneal  edges  were  purposely  excluded 
from  the  sutures,  and  the  animal  was  not  killed  for  a  day  or 
two,  intestine  or  omentum  adheres  to  the  inner  surface  of  the 
abdominal  wall,  thus  completing  the  peritoneal  sac  at  the  great 
risk  of  intestinal  obstruction,  to  say  nothing  of  a  want  of  firm 
union  and  subsequent  ventral  hernia.  Without  this  convincing 
demonstration  m  my  hands,  I  might  have  gone  on  for  years 
bowing  to  precepts  and  oblivious  of  principles,  sometimes  taking 
up  the  peritoneum  and  sometimes  leaving  it  loose,  with  per- 
plexity to  myself  and  danger  to  my  patients.  But  my  lesson 
was  learnt,  and  I  cannot  too  strongly  inculcate  it  upon  others. 
When  skin  or  mucous  membrane  are  divided,  their  edges  must 
be  brought  together  to  secure  direct  union.  If  they  be  in- 
verted, union  is  prevented.  The  exact  opposite  holds  good  with 
serous  membranes.  The  edges  should  be  inverted,  and  two 
surfaces  of  membrane  pressed  together,  so  that  the  sutures  are 
not  seen ;  and  the  effused  lymph  makes  so  smooth  a  surface 
that  even  the  line  of  union  cannot  be  seen.  This  appeared  to 
be  good  and  promising  work  for  1859,  and  I  felt  that  I  was 
announcing  what  was  indisputably  true,  but,  as  often  happens 
at  first,  the  fruits  did  not  equal  my  expectations,  for  I  had  the 
misfortune  to  lose  five  cases  out  of  the  eleven  which  I  did 
during  the  year,  three  in  hospital  and  two  in  private  practice. 

The  translation  in  1860  of  Kiwisch's  Chapters  on  Diseases 
of  the  Ovaries  by  Clay,  of  Birmingham,  with  the  very  valuable 
tables  appended  to  the  work,  must  be  regarded  as  greatly 
assisting  in  the  progress  of  ovariotomy  in  this  country.  Mr. 
Baker  Brown's  success    with    the   cautery,  Dr.   Tyler  Smith's 


MY   FIRST    BOOK   OF    CASES   IN    1864  199 

revival  of  the  practice  of  returning  the  pedicle  with  the  liga- 
ture around  it,  and  the  numerous  published  cases  of  Hutchin- 
son, Bryant,  Murray,  and  other  surgeons,  have  all  had  their 
share  in  the  general  result. 

Within  the  next  five  years  I  completed  my  hundred  and 
fourteen  operations,  and  at  the  end  of  them  in  1864  published 
my  first  book,  which  was  a  record  of  all  the  cases  with  com- 
mentaries, such  as  the  experience  acquired  in  conducting  them 
and  the  discussions  of  the  day  seemed  to  make  it  a  duty  to  lay 
before  the  public.  On  taking  up  this  subject  as  a  matter  of 
study  and  trial,  just  at  the  crisis  when  obloquy  was  the  thickest 
and  opposition  the  strongest,  I  felt  that,  in  securing  the  progress 
which  I  hoped  to  make,  nothing  but  the  most  open  frankness 
would  carry  conviction  of  my  success,  or  in  case  of  failure 
justifj  the  attempt.  I  was  not  unconscious  of  the  fact  that 
howe\er  much  I  might  devote  myself  to  it  as  a  professional 
obligation,  and  as  a  response  to  a  despairing  cry  from  a  crowd  of 
hopeless  women,  it  was  looked  upon  as  a  Quixotic  surgical  enter- 
prise which  had  baffled  others,  and  from  which  many  had  with- 
drawn discomfited.  I  therefore  pledged  myself  to  make  known 
through  the  press  all  that  I  did  and  all  that  befel  me,  and  my 
book  was  the  formal  redemption  of  that  pledge,  gathering  up 
as  it  did  all  the  isolated  details  of  my  practice,  and  the  scat- 
tered remarks  published  from  time  to  time  in  the  journals. 
During  this  period  of  five  years,  and  in  treating  the  long  series 
of  cases  as  it  then  seemed,  nearly  all  the  questions  of  practical 
importance  and  speculative  interest  came  up  for  consideration, 
and  were  rendered  intensely  pertinent  from  the  urgency  of 
their  actual  application.  Up  to  the  time  of  my  beginning  to 
operate,  there  was  but  little  concord  among  my  predecessors  as 
to  the  mode  of  doing  the  operation,  and  scarcely  any  reference  to 
scientific  principles  in  choosing  this  or  that  course.  Ignorance 
of  anaesthetics  had  long  kept  so  formidable  a  proceeding  out  of 
the  hands  of  all  but  the  most  daring  of  surgeons,  and  out  of 
the  thoughts  of  any  but  the  most  desperate  of  patients.  But 
now,  in  the  calmness  of  ether  and  chloroform,  and  with  the 
possibilities  of  the  older  surgeons  reduced  to  demonstrated  facts, 
attention  began  to  be  concentrated  upon  details  and  accidents. 
Problems  of  diagnosis,  the  means,  as  Hunter  expressed  it,  'of 
knowing  beforehand    that  the   circumstances  would   admit  of 


200  LENGTH    OF   INCISION 

such  treatment,'  the  relative  safety  of  long  or  short  incisions,  the 
mode  of  dealing  with  the  pedicle,  the  tolerance  of  the  peri- 
toneum, the  best  way  of  closing  the  wound,  the  value  of  opium 
in  connection  with  the  operation,  the  temperature  and  regimea 
to  be  observed,  the  distinction  between  peritonitis  and  reac- 
tion, the  nature  and  cause  of  septicaemia,  and  the  after  conse- 
quences of  the  operation  ;  all  these  and  other  subjects,  affecting, 
by  the  way  in  which  they  might  be  decided,  the  results  of 
ovariotomy,  were  presenting  themselves  to  the  practitioner  and 
demanding  his  judgment.  It  would  have  been  absurd  on  my 
part  to  pretend  that  I  was  arriving  at  absolute  truth,  or  to 
enunciate  anything  like  unquestionable  maxims.  But  as  facts 
accumulated,  as  1  became  familiarized  with  difficulties,  aware  of 
sources  of  danger,  and  learnt,  either  by  trial  or  from  others,  better 
modes  of  procedure,  I  formed  opinions,  acted  upon  them,  and 
offered  them  for  criticism.  Some  stand  their  ground,  ethers 
have  had  the  common  lot  of  fallacies ;  but  true  or  false,  they 
were  adopted  according  to  the  light  of  the  day,  and  I  cannot 
be  responsible  for  not  finding  out  the  whole  truth,  or  not  see- 
ing better  than  others  in  the  same  darkness.  I  have  often 
regretted  that  I  failed  to  become  sooner  acquainted  with  the 
valuable  clinical  lecture  of  Mr.  Caesar  Hawkins,  which  would 
have  cleared  my  way  through  some  difficulties,  and  dissipated 
some  shadows  which  perplexed  me.  But  on  reference  to  my 
volume  of  1864,  it  will  be  seen  that  I  soon  came  to  the  con- 
clusion that  it  was  a  matter  of  no  insuperable  difficulty  to 
decide  upon  the  practicability  of  the  operation,  and  that  an 
exploratory  incision  was  a  justifiable,  sometimes  useful,  and 
almost  always  a  harmless  proceeding.  When  Keith  can  tell  us 
that  only  twice  out  of  his  many  cases  has  he  been  deceived  as 
to  the  nature  of  his  tumours,  even  the  shade  of  William 
Hunter  must  be  appeased.  With  regard  to  the  incision,  it 
wanted  no  magician  to  demonstrate  that  length  was  a  relative 
quantity,  that  it  would  be  as  stupid  to  make  a  cut  ten  inches  long 
for  the  extraction  of  a  tumour  the  size  of  a  cricket-ball,  as  it 
would  be  madness  to  try  to  drag  a  semi-solid  multilocular  mass 
through  Dr.  Jeiffreson's  minimum  opening,  and  I  therefore 
acted  upon  the  rule  of  giving  myself  room  according  to  my 
case. 

But,  as  will  be  seen  by  my  table  of  incisions,  I  have  always 


TREATMENT    OF   THE    PEDICLE  201 

tried  to  keep  as  near  the  safe  medium  length  as  possible,  and 
it  would  sometimes  happen  that  such  an  opening  was  too  small 
for  a  big  multilocular  tumour  to  be  dragged  through  as  it  was. 
The  trocar  did  very  little  more  than  if  it  had  been  stuck  into  a 
sponge.  There  are,  however,  more  ways  than  one  out  of  a 
difficulty  if  you  only  look  at  it  calmly.  In  such  a  case  of  dis- 
proportion between  cut  and  bulk,  I  soon  began  to  take  the 
simple  alternative  of  breaking  down  the  interior  of  the  tumour 
with  my  hand,  till  the  antagonism  was  adjusted,  and  thus 
gained  another  point  in  rendering  the  operation  easier,  and 
ensuring  its  completion  in  many  cases  which  would  formerly 
have  been  abandoned. 

As  to  the  pedicle  there  was  more  hesitation.  No  one  knew 
exactly  what  should  be  done.  I  tied  it  and  kept  the  ligatures 
out  through  the  wound,  as  others  had  advised.  I  tied  it  and  let 
it  drop  into  the  abdomen.  I  fixed  it  in  the  wound  with  a  liga- 
ture and  pins.  I  secured  it  outside  the  wound  with  a  clamp.  I 
cauterised  it  and  left  it  in  situ.  I  combined  the  cautery  and 
ligature.  I  made  a  solitary  essay  with  the  ecraseur,  and  I  con- 
joined and  modified  most  of  these  procedures.  Every  plan  had 
its  special  difficulties  and  dangers,  and  one  peculiarity  of  all 
this  tentative  work  was,  that  it  brought  the  disadvantages  more 
conspicuously  into  view  than  the  advantages.  It  is  impossible 
now,  with  the  results  of  the  experience  of  twenty  years  tabu- 
lated and  criticized,  and  practice  running  in  two  or  three  equally 
approved  grooves,  for  any  one  to  form  an  idea  of  the  perplexity 
which  formerly  made  every  movement  in  advance  dubious. 
Circumstances  sometimes  took  away  the  ground  of  option,  as 
when  the  pedicle  was  too  short  to  be  brought  out  of  the  wound 
and  clamped.  But  upon  the  whole,  in  accordance  with  what 
was  the  then  belief,  that  a  tied  pedicle,  whether  enclosed  or  left 
to  drain  through  an  aperture,  must  undergo  the  process  of 
gangrene  and  sloughing,  the  notion  of  extra-peritoneal  treat- 
ment was  theoretically  right,  and  it  was  this  conviction,  together 
with  some  practical  objections  to  the  ligature  and  cautery,  that 
led  me  to  give  the  preference  to  fixation  externally  by  the 
clamp.  The  greater  part  of  the  pedicles  during  this  section  of 
n  iv  operative  work  were  treated  in  this  way.  There  were  no 
statistics  to  judge  by,  but  I  seemed  to  be  doing  better  with  it; 
and   later  on,  when  numbers  augmented,  they  proved  that  the 


-'  ■ 


202 


THE   CLAMP 


mortality  in  these  cases  was  less  than  the  general  average,  and 
vastly  lower  than  that  given  by  the  ligature.  It  is  true  that 
the  cases  I  did  with  the  cautery  turned  out  well,  but  they  were 
few  in  number ;  and  though  Baker  Brown  was  concurrently 
doing  better  still  with  it,  I  was  not  assured  of  the  fact  at  the 
time.  Besides,  it  is  not  in  the  nature  of  things  that  one  man 
can  guarantee  himself  the  same  success  as  another  in  adopting 
his  practice,  especially  when  that  practice  is  a  matter  of 
manipulation.  And  further,  I  must  admit  such  a  want  of 
confidence  in  the  efficacy  of  the  cautery  as  would  have  morally 
incapacitated  me  from  continuing  the  operation  by  such  means. 
Whether  right  or  wrong  then,  the  clamp  gained  its  ascendency 
and  I  continued  to  use  it.  It  has  since  been  imputed  to  me 
that  by  so  doing  I  retarded  the  progress  of  ovariotomy,  that  I 
deterred  others  from  venturing  upon  an  operation  involving  so 


fearful  a  mortality  as  that  of  one  in  four  or  five.  But  it  is  easy 
to  make  such  reflections  retrospectively,  and  I  can  only  retort 
that  without  the  leading  of  the  clamp  and  the  support  which 
the  clamp  results  gave  to  the  trial  of  other  surgical  expedients, 
some  of  those  who  are  the  successful  ovariotomists  of  to-day 
would  never  have  been  ovariotomists  at  all. 

The  primitive  clamp  was  nothing  more  than  the  carpenter's 
callipers,  but  they  were  clumsy  and  inconvenient.  Mr.  Hutch- 
inson introduced  them,  and  his  first  improvement  was  to  make 
the  handles  movable.  To  them  succeeded  a  variety  of  ingenious 
arrangements  of  bars  and  rings  made  with  a  view  to  equalise 
the  pressure,  and  to  render  the  escape  of  tissue  impossible. 
Some  were  parallel,  others  circular,  some  were  too  ponderous, 
others  too  slight. 


MODIFICATIONS    OF   THE    CLAMP 


20 


The  drawing  on  preceding  page  was  published  in  1858.  It 
shows  the  first  attempt  at  a  parallel  clamp  before  I  added  a  screw 
at  each  end,  and  it  shows  very  well  how  a  pedicle  not  subjected 
to  circular  constriction  would  be  so  elongated  from  side  to  side 
as  to  prevent  closure  of  the  wound. 

My  first  attempt  to  improve  upon  this  instrument  resulted 
in  the  manufacture  of  two  fenestrated  blades,  which  were  made 
to  exert  parallel  compression  by  a  screw  at  each  end.  This 
instrument  is  still  described  as  my  clamp,  and  the  original 
sketch  of  it  here  given  has  been  copied  by  Simpson  and  other 
writers.  It  forms  the  basis  of  the  clamps  known  as  Dawson's 
and  Atlee's,  both  of  which  have  been  successfully  used  in 
America.  They  appear  to  me,  however,  to  be  too  slight  in 
construction  ;  and  I  very  much  prefer  my  own  simpler  form  of 
the  instrument,  even  although  it  may  be  necessary  to  compress 


S\ 


1- -N--.); 


some  of  the  wide,  uneven,  and  expanding  pedicles  before  finally 
fixing  the  clamp. 

Atlee  afterwards  added  holes  for  pins,  by  which  the  pedicle 
can  be  compressed,  or  prevented  from  extending  laterally,  as 
the  clamp  is  tightened.  I  had  tried  to  attain  the  same  end  by 
carrying  a  ligature  through  the  fenestras  of  the  blades,  and 
making  circular  compression  upon  the  pedicle  while  the  screws 
were  bringing  the  blades  together.  Without  some  precaution  of 
this  kind,  the  pedicle  is  so  expanded  that  it  becomes  a  serious 
impediment  to  entire  closure  of  the  wound  ;  and  if  one  part  of 
the  pedicle  is  thicker  than  another,  the  thicker  part  interferes 
with  the  complete  compression  of  the  thinner,  which  is  then 
;ij»f  to  Blip. 

After  using  this  inslrument  for  some  months  I  found  it  less 


204  THE   CLAMP   IN   EXTRA-PERITONEAL 

easy  of  application  than  the  modified  calliper  clamp,  and  I 
made  some  improvements  in  the  latter,  trying  three  different 
forms  of  movable  connecting  joint,  different  forms  of  the  com- 
pressing surfaces,  from  the  perfectly  smooth  and  flat  to  grooves 
and  ridges  falling  one  into  the  other,  or  a  convex  surface 
received  into  a  concave,  or  one  where  a  projection  in  the  centre 
was  received  into  a  corresponding  hollow  ;  and  I  found  the 
most  trustworthy  was  that  suggested  by  Kiichenmeister,  of 
Dresden,  where  oblique  ridge  and  furrow  on  one  blade  exactly 
meet  the  corresponding  elevations  and  depressions  on  the  other. 
If  properly  made,  these  surfaces,  when  pressed  together,  will 
not  allow  a  piece  of  fine  tissue  paper  to  be  drawn  between 
them.  The  smooth  arc  not  affording  a  sufficient  hold  upon  the 
screw,  the  upper  surface  of  the  arc  was  roughened.  The 
straight  instrument  lying  awkwardly  after  application,  and 
sometimes  causing  painful  pressure  at  its  angles,  I  had  it 
curved  and  all  the  edges  carefully  rounded  off.  Various  modes 
of  fixing  movable  handles  were  tried,  and  none  proving  very 
satisfactory,  I  substituted  a  large  pair  of  forceps  for  the  handles, 
so  made  that  it  would  fit  clamps  of  all  sizes,  and  one  pair  of 
forceps  serve  for  any  number  of  clamps.  Additional  thickness 
was  given  to  that  part  of  the  blade  in  which  the  screw  passes 
through  to  the  arc.  When  well  made  this  instrument  holds 
very  securely  in  most  cases  where  a  clamp  can  be  applied,  but 
occasionally  the  auxiliary  aid  of  a  ligature  is  necessary;  for 
instance,  if  the  pedicle  be  made  up  partly  by  the  thickened 
Fallopian  tube  or  utero-ovarian  ligament,  and  partly  by  thin 
membranous  expansions  of  the  broad  ligament  running  towards 
the  colon  or  csecum,  the  clamp  alone  is  not  trustworthy.  The 
thin  part  of  the  pedicle  is  not  compressed  because  the  thicker 
parts  of  the  pedicle  keep  the  blades  too  far  apart;  and  after  the 
cyst  is  cut  away,  the  thin  portion  of  the  pedicle  is  very  apt  to 
slip  inwards.  I  have  seen  very  troublesome  bleeding  arise  in 
this  way,  which  might  easily  have  been  prevented  if  the 
circular  compression  of  a  ligature  had  been  exerted  before  the 
application  of  a  clamp.  I  attempted  to  make  a  circular  clamp, 
and  different  makers  tried  to  carry  out  my  wishes,  but  the  only 
promise  of  success  was  from  one  made  for  me  by  Meyer.  After 
occasionally  using  this  instrument  I  found  that  it  would  cut 
through  some  varieties  of  pedicle  just  like  scissors.     I   had 


TREATMENT    OF   THE    PEDICLE  205 

more  than  once  to  suppress  troublesome  bleeding,  so  that  after 
a  short -trial  of  this  clamp  I  returned  to  the  use  of  the  calliper 
clamp,  with  the  modifications  which  I  have  described.  The 
mode  of  applying  the  clamp  will  be  shown  when  the  various 
plans  of  dealing  with  the  pedicle  are  considered  in  the  chapter 
on  the  operation. 

It  will  be  seen  that  the  idea  did  not  change,  and  that  the 
alterations  of  the  joints,  screws,  curves  and  surfaces  were  made 
for  convenience,  and  what  was  known  in  England  as  my  clamp 
very  well  answered  its  purpose  as  long  as  it  was  wanted  to 
carry  out  the  extra-peritoneal  treatment. 

This  idea  of  extra-peritoneal  treatment,  as  I  have  said,  had 
more  to  do  with  the  fear  of  shutting  up  noxious  putrefactive 
matter  coming  from  the  strangulated  pedicle  than  anything 
else.  But,  as  well,  we  all  at  that  time  looked  at  the  peritoneum 
with  a  kind  of  reverential  fear,  and  were  always  under  the 
apprehension  of  its  resenting  any  neglect  or  interference  by 
some  itic  action.  No  one  had  any  clear  notion  of  its  tolerance 
of  everything  that  was  not  in  its  nature  harmful.  Men  who 
had  cut  it  open,  torn  through  adhesions  on  its  surface,  and  left 
it  exposed  for  perhaps  half  an  hour  while  they  were  liberating 
a  tumour,  were  as  anxious  to  shut  it  up  hermetically  as  soon  as 
they  had  finished  as  if  they  knew  it  to  be  hydrophobic  or 
aerophobic.  I  was  not  far  behind  the  ruling  opinions,  and 
if  any  one  had  asked  me  why  I  united  the  wound  so  closely 
round  the  pedicle,  they  would  have  found  their  answer  in  these 
words  in  my  book,  '  The  fear  is  that  peritonitis  may  be  set  up 
by  leaving  any  opening.'  It  was  a  curious  instance  of  incon- 
sistency, because  in  the  very  same  page  I  advocate  a  free  open- 
ing for  the  exit  of  serum  if  any  there  should  be.  It  was  a 
remnant  of  antique  superstition,  and  we  had  not  yet  fuJly  learnt 
to  estimate  the  eclecticism  of  the  peritoneum.  We  soon,  how- 
ever, found  out  that  while  a  very  little  fluid  which  had  no 
business  to  be  there  irritated  as  much  as  a  sponge,  we  might 
profitably  reopen,  wash,  cleanse  and  drain.  The  step  from  this 
to  making  a  free  passage  through  the  vaginal  wall  was  not  diffi- 
cult, and  this  I  did  in  my  thirty-sixth  case,  thereby  saving  the 
life  of  the  patient.  Afterwards  I  had  only  to  regret  sometimes 
not  having  done  it  with  sufficient  boldness.  But  the  process 
which  came  to  be  called  the  toilette   of  the  peritoneum,  both 


206 


POSITION    OF    THE    PATIENT 


primary  and  secondary,  soon  made  progress,  and  is  now  not  the 
least  efficient  factor  of  the  general  success  of  the  operation. 

Some  of  the  surgeons  who  had  operated  before  me,  placed 
the  patient  in  a  sitting  posture  near  the  edge  of  the  bed,  with 
her  legs  widely  separated,  her  feet  supported  on  stools,  and  her 
back  and  head  resting  on  pillows  ;  and  a  few  do  so  still.  I 
followed  this  practice  in  my  first  three  cases,  but  it  was  so  diffi- 
cult to  keep  the  patient  properly  covered,  she  was  so  apt  to 
become  faint  under  the  influence  of  chloroform,  there  was  so 


much  difficulty  in  preventing  the  escape  of  the  intestines, 
and  in  completing  satisfactorily  the  various  steps  of  the  opera- 
tion, that  I  tried  the  recumbent  position  in  my  fourth  case,  and 
I  have  kept  to  it  ever  since. 

In  Simpson's  '  Lectures  on  Ovariotomy,'  published  in  the 
'  Medical  Times  and  Gazette,'  and  reprinted  in  his  collected 
works,  this  drawing  which  I  prepared  for  him  was  introduced  to 
show  the  couch  on  which  I  performed  a  great  many  of  my 
earlier  operations.  It  was  very  convenient,  but  it  became 
troublesome    to  carry  such  a  piece    of  furniture    about  from 


CLOSURE   OF   THE   WOUND  207 

house  to  house.  Two  common  dressing-tables,  which  may  be 
found  wherever  we  go,  placed  T  fashion,  soon  commended 
themselves  as  equally  fit  for  the  purpose,  and  have  served  me 
ever  since.  The  recumbent  position  is  incontestably  safer  for 
the  patient  as  well  as  more  agreeable  to  the  surgeon,  and  I 
believe  it  is  partly  owing  to  my  adherence  to  it  that  through 
all  my  operations  I  have  never  had  any  serious  trouble  from 
fainting  and  collapse,  and  have  been  saved  the  misery  of  seeing 
a  woman  die  on  the  table. 

As  with  my  experiments  on  animals  so  with  my  patients,  I 
began  closing  the  wound  with  hare-lip  pins,  passing  them 
through  the  whole  thickness  of  the  abdominal  wall  at  intervals 
of  an  inch.  Each  pin  perforated  the  skin  about  an  inch,  and 
the  peritoneum  about  half  an  inch  from  the  incision  on  either 
side,  so  that  when  the  two  opposed  surfaces  were  pressed 
together  upon  the  pin,  the  two  layers  of  peritoneum  were  in 
contact  with  each  other.  But  I  soon  began  to  use  and  prefer 
sutures  to  pins,  and  tried  different  materials  for  this  purpose. 
Metallic  sutures  were  then  coming  into  vogue,  and  in  1861  I 
was  trying  silver.  In  1862  I  used  platinum  sutures  for  my 
thirty-sixth  case,  to  ascertain  if  any  advantage  would  arise  from 
the  use  of  a  metal  which  would  not  oxidize  like  silver  or  iron, 
and  remembering  the  use  of  platinum  sutures  twenty  years 
before  by  Mr.  Morgan  at  Gruy's  Hospital.  But  I  have  scarcely 
ever  seen  so  much  suppuration  in  the  track  of  the  sutures  as  in 
this  case  ;  and  it  taught  me  to  look  to  the  size  of  the  needle, 
the  size  and  smoothness  of  the  thread  or  silk,  the  tightness  with 
which  it  is  tied,  and  the  time  it  is  left,  as  having  more  to  do 
with  suppuration  or  sloughing  than  the  material  of  which  the 
suture  is  composed. 

A  little  later  in  October  of  the  same  year,  wishing  to 
observe  any  difference  between  silk  and  metallic  sutures,  I 
passed  four  deep  sutures,  one  of  silk,  one  of  iron  wire,  one  of 
silver  wire,  and  one  gilded  hare-lip  pin.  I  removed  them  all 
forty-eight  hours  after  operation,  and  found  the  wound  equally 
well  united  throughout.  The  silk  suture  was  removed  with 
least  pain  to  the  patient,  the  silver  wire  next,  and  the  iron  wire, 
being  harder,  caused  most  pain  in  removal.  In  other  operations 
I  had  tried  horsehair  and  the  fine  catgut  used  for  guitar  strings, 
but  I  was  coming  to  the  conclusion  that  nothing  answered  so 


208  SUTURES 

well  for  sutures  on  the  whole  as  good  silk  well  twisted.  Sub- 
sequent trials  of  silkwormgut,  catgut,  tendon,  and  telegraph 
wire  coated  with  gutta-percha,  have  all  confirmed  me  in  my 
impression  as  to  the  superiority  of  silk  if  tied  tightly  enough  to 
bring  the  edges  of  the  wound  together  accurately,  yet  not  so 
tight  as  to  strangulate  the  intervening  tissues.  It  need  never 
be  removed  before  the  seventh  day,  and  may  be  left  till  the 
ninth  or  tenth,  if  so  desired,  without  any  harm.  My  impres- 
sions and  conclusions  of  1862  remain  my  convictions  in  1882  ; 
and  the  fact  that  I  have  uniformly  used  only  silk  for  my  liga- 
tures and  sutures  all  through  the  several  stages  of  my  gradually 
improving  results,  shows  what  I  said  in  the  beginning  to  be 
true,  that  the  material  is  of  less  importance  than  the  way  of 
managing  it.  It  was  not  long  after  my  changing  the  pins  for 
sutures  in  fixing  together  the  edges  of  the  wound  that,  find- 
ing there  was  a  chance  of  suppuration  from  their  being  left  too 
long,  and  wishing  to  ascertain  how  soon  they  could  be  removed 
with  safety,  I  adopted  the  plan  of  supporting  the  abdominal 
wall  with  long  straps  of  adhesive  plaster,  and  I  still  continue  to 
use  them  and  a  simple  flannel  bandage. 

In  looking  over  the  notes  of  the  period  about  which  I  am 
now  writing,  it  is  curious  to  mark  the  vagueness  of  all  our 
notions  as  to  the  import  of  certain  symptoms  and  conditions. 
Even  such  a  point  as  the  difference  between  reaction  and  peri- 
tonitis was  not  clear  to  every  one.  My  fortieth  patient  was  a 
very  young  woman,  who,  in  two  years'  time,  had  been  modelled 
by  her  disease  into  the  most  perfect  type  of  an  ovarian  martyr, 
and  who  rebounded  into  health  with  a  rapidity  and  persistence 
absolutely  marvellous  when  once  relieved  from  her  oppression. 

'  At  first  the  sudden  removal  of  such  a  strain  seemed  to 
be  almost  too  much  for  the  system ;  it  seemed  as  if  it  were 
difficult  for  heart  and  lungs  to  play  with  even  balance  under  so 
much  lighter  a  task — the  pulse  was  a  little  hurried,  the  face 
flushed,  the  skin  rather  hot.  But  soon  we  had  a  free  perspi- 
ration, and  all  went  well.  Just  at  this  time  I  was  a  little 
amused  by  the  different  views  taken  of  the  case  by  two  worthy 
friends  of  mine.  Each  observed  the  same  symptoms,  but 
interpreted  them  very  differently.  One,  more  at  home  in  1  he 
dissecting-room  and  the  dead-house  than  at  the  bedside,  began 
to  speak  ominously  of  peritonitis,  to  suggest  leeches  and  calomel 


INTERPRETATION    OF   SYMPTOMS  209 

and  opium,  and  seemed  surprised  at  my  being  content  to  let 
what  I  thought  well  alone.  My  other  friend,  whose  life  had 
been  passed  in  watching  and  treating  disease — not  merely  in 
examining  and  collecting  the  fragments  of  the  wreck  after  the 
storm  has  left  it  shattered  on  the  shore,  but  in  noting  the 
warnings  of  the  coming  tempest,  and  in  learning  how  to  trim 
sail,  to  bear  up  or  to  lay  to,  and  what  course  to  steer  to  reach  a 
safe  anchorage — this  true  pathologist  saw  nothing  to  alarm 
him  in  the  quickened  pulse,  the  warm  skin,  or  the  flushed  face ; 
he  looked  quite  delighted,  and  exclaimed,  "  What  nice  reaction !  " 
He  exactly  expressed  my  own  thoughts,  and  two  small  opiates 
given  during  the  night  after  the  operation  to  quiet  pain,  were 
the  only  medicines  of  any  kind  which  this  patient  took  during 
her  convalescence.' 

Nor  has  her  subsequent  career  belied  the  good  augury  of  her 
vigorous  recovery.  She  married  and  bore  children,  has  buried 
three  husbands,  and  is  now  in  1882  a  promising  widow  of  less 
than  forty  years  of  age. 

I  have  more  than  once  had  occasion  to  refer  to  my  fourth 
case,  and  I  turn  to  it  again  because  there  is  often  more  practical 
good  to  be  gained  by  sifting  the  details  or  dwelling  on  the 
history  of  one  unfortunate  event  than  by  skimming  over  a 
sea  of  statistics,  or  ballooning  through  a  cloud  of  speculation. 
I  have  said  that  I  did  not  know  why  my  patient  died,  and 
at  the  time  that  was  quite  true.  In  the  published  table  of 
cases  the  cause  of  death  was  set  down  as  septicaemia.  This 
was  an  after  thought.  For  what,  in  truth,  did  any  of  us  know 
about  septicsemia  in  1859?  One  may  judge  how  little  it  was 
by  the  way  in  which  I  expressed  myself  in  a  paper  read  before 
the  Medical  and  Chirurgical  Society  the  month  after  I  had 
operated. 

I  was  asking  the  meeting  to  endeavour  to  help  me  in  esti- 
mating the  share  which  each  of  four  agencies  that  I  suggested 
had  in  causing  the  death.  I  had  my  doubts  about  the  opium 
she  had  taken,  for  just  then  it  was  the  custom  to  use  it  very 
freely.  I  suspected  bleeding  from  the  pedicle,  at  the  moment 
of  removing  the  tumour,  might  have  done  mischief.  And  I  was 
not  disinclined  to  fortify  myself  against  self-reproach  by  calling 
to  mind  the  collapse  which  Simpson  had  so  well  described  as  an 
accident  peculiarly  liable  to  occur  after  operations  about  the 

p 


210  PRACTICAL   LESSONS    FROM   EARLY    CASES 

pelvic  organs,  and  for  which  no  sufficient  explanation  has  been 
offered.  But  I  emphatically  asked,  '  Did  she  die  from  peri- 
tonitis ? '  adding,  '  Some  who  consider  the  amount  of  lymph 
effused,  and  the  quantity  of  serum  found  in  the  peritoneal 
cavity,  would  answer  this  question  unhesitatingly  in  the  affirma- 
tive. But  I  doubt  if  simple  peritonitis  was  sufficient  to  cause 
such  sudden  collapse.  It  was  partial,  confined  to  the  visceral 
layer  opposed  to  the  wounded  surface  only,  not  dipping  down 
among  the  coats  of  intestine.  My  impression  is,  that  if  perito- 
nitis killed  her,  it  was  indirectly,  by  the  formation  of  a  morbid 
poison.  The  serum  was  very  acrid,  it  made  Dr.  Aitken's  hands 
smart  for  some  time ;  had  he  wounded  himself,  in  all  probability 
he  would  have  suffered  from  morbid  poisoning.  Had  he  at- 
tended a  woman  in  labour,  in  all  probability  that  woman  would 
have  had  puerperal  peritonitis.  If,  then,  my  patient  could 
generate  a  poison  capable  of  killing  other  people,  may  it  not 
have  killed  her  ?  It  was  probably  formed  only  from  the  in- 
flamed portion  of  the  peritoneum,  the  other  portion  being  quite 
capable  of  absorbing  rapidly.'  Here  then  was  the  idea  of 
poison  superadded  to  that  of  peritonitis  ;  but  the  patient  was 
blamed  for  making  it  herself,  and  perhaps  fairly,  as  she  had  suf- 
fered from  an  eruption  of  herpes  on  one  side  of  the  chest  only 
a  few  days  before.  But  nothing  was  as  yet  said  about  the  like- 
lihood of  its  having  been  brought  to  her.  Two  years  later  I 
had  personal  proof  of  what  this  poison  could  do.  I  pricked 
myself  in  examining  the  body  of  a  patient  who  died  under 
similar  circumstances,  and  I  was  ill  enough  to  make  me  say  in 
writing  the  report  of  the  case  :  '  A  poison  which  affected  me 
so  severely  in  a  small  dose  might  easily  kill  any  one  in  a  larger 
dose.  I  recovered  after  the  absorption  of  a  fraction  of  a  drop  ; 
but  the  poor  woman  was  overpowered  by  the  quantity  taken  up 
by  her  own  absorbents.'  Here  again  one  part  of  the  peritoneum 
was  accused  of  distilling  and  another  part  of  absorbing  the 
venomous  fluid.  Now  I  thought  I  had  learnt  a  grand  practical 
lesson,  which  I  reiterated  in  all  that  I  wrote,  that  our  business 
was  to  let  out  this  fluid  as  soon  as  we  saw  signs  of  its  collecting 
in  the  peritoneal  cavity,  either  by  opening  the  wound  or  tapping 
by  the  vagina,  or  any  other  means  by  which  we  could  give 
it  exit.  This  policy  of  ejectment  was  very  well  so  far  as  it 
went,  and  without  question  some  lives  were  saved  by  it.    But 


ORIGIN    OF    ANTISEPTICS  211 

it  was  working  at  the  wrong  end  of  the  problem.  Still  the 
missing  link  in  the  ratiocination  of  this  subject  was  close  at 
hand.  A  parturient  woman  fulfilling  one  of  the  natural  func- 
tions of  life  could  not,  except  under  the  most  abominable  con- 
ditions, be  looked  upon  as  a  focus  of  self-engendering  poison. 
Yet  she  was  occasionally  overtaken  by  puerperal  peritonitis, 
and  the  cry  immediately  was,  '  Where  did  it  come  from  ? '  Im- 
portation was  the  accepted  explanation,  and  accoucheurs  fell 
into  the  category  of  '  suspected  persons.'  I  had  now  the  clue  in 
my  hand,  and  in  less  than  a  year  it  led  me  to  an  understanding 
of  my  difficulties.  Two  cases,  my  seventy-fourth  and  seventy- 
fifth,  proved  fatal,  and  the  surroundings  were  more  than  suspi- 
cious. This  led  to  the  exclusion  of  all  midwifery  practitioners 
from  my  operations  unless  they  could  present  a  clean  bill  of 
health,  and  subsequently  to  the  declaration,  so  much  quizzed, 
which  was  obligatory  upon  every  person  wishing  to  see  my 
hospital  cases.  Then  followed  other  precautions,  and  I  was  to 
be  seen  using  carbolic  acid  and  the  hyposulphites  in  my 
ovariotomy  wards. 

The  famous  asseveration  and  prophecy  of  Sir  James  Paget 
before  one  of  the  meetings  of  the  British  Medical  Association, 
'that  some  of  the  deaths  after  surgical  operations  were  pre- 
ventable, and  that  the  mortality  will  be  reduced  if  the  members 
of  the  association  will  decide  that  it  shall  be,'  was  not  without 
its  influence.  At  the  Cambridge  meeting  in  1864,  I  treated  of 
hospital  atmosphere,  organic  germs  as  causes  of  excessive 
mortality,  and  commented  on  the  researches  of  Polli  with 
sulphur  and  the  sulphites.  Here  then  were  theory  and  practice 
brought  into  accord,  and  my  quarantine,  drainage,  vaginal  tap- 
pings, and  chemical  remedies  may  justly  be  scheduled  as  the 
concrete  form  of  antisepsis  which  has  since  become  volatilized 
into  the  germicidal  spray  of  Lister. 

The  progress  of  ovariotomy  in  England  has  thus  been 
brought  to  the  issue  of  my  first  book  at  the  end  of  the  year 
1864.  It  does  not  profess  to  trace  the  general  progress  of  the 
operation,  or  to  estimate  the  value  of  other  modes  of  treatment 
adopted  by  the  various  surgeons  who  were,  like  myself,  making 
their  experience.  But  as  a  simple  record  of  what  I  did,  of  the 
oscillating  opinions  on  many  points  of  practice,  of  the  way  in 
which  light  partially  dawned   upon  some  of  the  obscurities  of 

p  2 


212  PROGRESS   FROM    1864 

the  subject,  of  the  anxious  unravelling  of  some  of  the  mixed 
threads  of  logic  and  experiment  which  led  to  definite  lines  of 
action,  of  the  discussions,  consultations,  and  workings  with  a 
great  number  of  estimable  and  accomplished  men,  many  of 
whom  have  remained  friends,  and  become  successful  co-ope- 
rators, it  has,  I  believe,  been  useful.  I  was  not  prepared  to 
write  a  systematic  treatise,  I  was  not  in  a  position  to  dogmatise, 
but  I  had  tided  over  initial  obstacles ;  and  though  I  could  not 
expect  unvarying  success,  I  had  done  enough  to  put  down 
opposition,  and  to  demonstrate  the  fact  that  I  was  following  a 
legitimate  course,  and  had  reason  to  hope  better  things  for  the 
future.  Whatever  else  the  book  may  be,  and  however  little  I 
may  be  disposed  to  claim  for  it  a  place  as  a  piece  of  surgical 
literature,  it  has  the  value  of  truthfulness  ;  and  as  none  of  my 
cases  have  since  been  so  fully  described,  it  even  now  serves  me 
as  a  wreck-chart  and  a  guide. 

During  the  seven  years  and  a  half  which  succeeded,  I  com- 
pleted five  hundred  cases  of  ovariotomy,  and  in  the  autumn 
of  1872  published  my  book  on  ovarian  disease.  It  was  not  like 
the  first,  a  case-book,  but  contained  a  general  summary  of  all 
that  I  had  learnt  upon  the  subject,  and  with  regard  to  the 
operation,  the  fullest  practical  and  statistical  information  at 
my  command.  I  had  all  through  carried  out  my  scheme  of 
periodically  reporting  progress.  Yet  I  felt  that  the  profession 
had  a  right  to  something  more  in  the  way  of  recapitulation  of 
facts,  and  summing  up  of  the  results  of  so  much  work  either  in 
the  way  of  operative  improvement  or  pathological  science.  I 
am  now  responding  to  the  call  for  a  second  edition,  and  that  is 
enough  for  me  to  say  about  it.  I  still  continued  to  do  the 
surgical  work  of  the  hospital,  having  been  all  through  assisted 
by  a  succession  of  younger  colleagues,  among  whom  I  may 
mention  especially  Dr.  Charles  Ritchie,  Dr.  Junker,  and  Dr. 
W.  Thomson.  The  promising  career  of  Ritchie,  to  my  great 
regret,  was  cut  short  by  a  melancholy  accident,  and  both  Junker 
and  Thomson  have  seized  opportunities  of  distinguishing 
themselves  otherwise  than  as  ovariotomists.  It  was  during 
this  time  that  Dr.  Richardson  brought  to  my  notice  his  investi- 
gations of  the  value  of  methylene  as  an  anaesthetic,  and  the 
apparatus  which  Junker  invented  for  its  convenient  administra- 
tion has  been  in  use  ever  since.     Chloroform  had  been  given 


TO    1877  213 

from  the  first  with  the  exception  of  a  few  trials  of  ether  and 
other  combinations,  but  it  was  quite  supplanted  by  methylene. 
I  may  also  congratulate  myself,  and  my  patients  too,  that  for 
several  years  past  this  valuable  remedy  has  been  administered 
by  my  friend,  Dr.  Day,  with  so  much  care  and  judgment,  that 
we  have  been  spared  all  anxiety  and  danger,  and  most  of  the 
annoyances  which  so  often  attend  the  employment  of  other 
anaesthetics. 

The  work  of  ovariotomy  was  now  becoming  a  matter  of 
routine.  Series  of  hundreds  succeeded  to  series  of  hundreds, 
and  happily  with  regularly  diminishing  losses.  Instruments 
were  sometimes  new-modelled,  and  there  were  modifications  of 
manipulative  details  and  after-treatment,  but  we  were  now 
acting  upon  principles  which  kept  us  pretty  nearly  in  a  given 
course,  and  made  the  service  of  the  sick  room  comparatively 
easy.  Dr.  Bantock  and  Mr.  Thornton  were  installed  as  joint 
surgeons  with  me  in  hospital,  and  not  only  took  a  part  in 
my  operations,  but  commenced  their  own  work  as  ovariotomists 
in  1875  or  1876.  They  had  every  opportunity  of  observing  my 
practice,  and  of  forming  their  opinions  as  to  the  expediency  of 
following  it  implicitly,  or  of  making  up  an  eclectic  code  of  their 
own  by  culling  the  fruits  of  other  men's  experience ;  but  I  can 
conscientiously  say  that  I  acted  towards  them  and  others  in  the 
spirit  of  a  remark  which  I  found  in  one  of  the  reviews  of  my 
book,  that  a  man  in  my  position  '  has  no  more  right  to  die  with 
the  hoarded  endowments  of  his  life  unrevealed  than  he  has  to 
commit  suicide.' 

The  incident  of  Mr.  Lister's  arrival  in  London  in  the  year 
1877  raised  the  question  of  the  applicability  of  his  system  to 
ovariotomy.  The  mortality  from  my  own  hospital  operations 
being  at  this  time  not  much  more  than  9  per  cent.,  I  hesitated 
about  venturing  upon  any  untried  proceedings  which  might 
interfere  with  results  then  so  satisfactory.  But  Mr.  Thornton, 
who  had  been  an  enthusiastic  pupil  of  Lister,  introduced  his 
mode  of  operating  and  dressing  in  all  its  integrity  at  the 
Samaritan,  and  Dr.  Bantock  for  a  time  followed  his  example. 
Some  other  novelties,  such  as  Dr.  Bantock's  non-alcoholic  after- 
treatment  and  Mr.  Thornton's  ice-cap  a  little  diversified  the 
routine  of  our  wards. 

After  twenty  years'   service  as  operating   surgeon   to  the 


214 


END   OF   MY   HOSPITAL   WORK 


Samaritan  Hospital  I  felt  myself  not  only  warranted  in  retiring, 
but  bound  to  make  way  for  my  junior  colleagues,  and  at  the  eDd 
of  the  year  1877  placed  my  resignation  in  the  hands  of  the 
committee.  At  their  request,  however,  I  retained  the  post  of 
consulting  surgeon.  My  last  ovariotomy  as  surgeon  to  the 
hospital  was  done  on  December  12,  and  after  it  I  made  a  few 
remarks  to  those  present,  giving  a  summary  of  my  work  in 
reference  to  these  cases.  They  were  published  in  the  '  Medical 
Gazette,1  and  the  following  table  showed  the  distribution  of  my 
operations  over  these  twenty  years  : — 


Years 

Cases 

Eecoveries 

Deaths 

1858 

3 

3 

0 

1859 

6 

4 

2 

1860 

2 

1 

1 

1861 

6 

3 

3 

1862 

13 

10 

3 

1863 

16 

11 

5 

1864 

14 

11 

3 

1865 

17 

13 

4 

1866 

15 

10 

5 

1867 

21 

17 

4 

1868 

32 

25 

7 

1869 

21 

14 

7 

1870 

24 

17 

7 

1871 

26 

18 

8 

1872 

30 

23 

7 

1873 

34 

25 

9 

1874 

29 

20 

9 

1875 

28 

20 

8 

1876 

42 

38 

4 

1877 

29 

26 

3 

Total 

408 

309 

99 

I  then  went  on  to  say  :  '  Now  let  us  see  how  far  increasing 
experience  has  affected  the  proportion  between  recoveries  and 
deaths  in  successive  years.  A  glance  at  the  table  will  show  you 
how  this  varies  in  the  several  years ;  but  we  want  larger 
numbers  for  anything  like  accurate  statistical  conclusions. 
This,  we  may,  perhaps,  gain  by  grouping  the  cases  together  in 
series  of  five  years.     I  have  done  this,  and  here  is  the  result : — 


Series  of  Years 

Cases 

Eecoveries 

Deaths 

First  five  years     .     . 
Second  five  years.     . 
Third  five  years   .     . 
Fourth  five  years. 

30 

83 

133 

162 

21 

62 

97 

129 

9 
21 
36 
33 

RESULTS  215 

If  we  take  the  last  two  years  only  (1876  and  1877),  we  find  71 
cases,  with  64  recoveries  and  only  7  deaths — a  mortality  just 
below  10  per  cent. 

'  Or  putting  these  facts  in  another  form,  and  dividing  the 
twenty  years  into  four  successive  periods  of  five  years  each,  it 
appears  that  in  the — 

First  five  years      ....  about  1  in     3  died 

Second  and  third  five  years  .        .  „  1   „  4     ,, 

Fourth  five  years  .         .         .         .  „  1    „  5     „ 

Last  two  years      .        .        .        .  „  1   „  10     „ 

'  But,  to  render  the  matter  more  clear,  I  arrange  these  cases 
in  another  table,  which  gives  us  at  once  the  number  of  cases, 
the  number  of  deaths,  and  the  percentage  of  recoveries : — 


Series  of  years 

Cases 

Deaths 

Eecoveries 

First  five  years  (1858  to  1862) 
Second  five  years  (1863  to  1867) 
Third  five  years  (1868  to  1872) 
Fourth  five  years  (1873  to  1877) 

Total 
Two  last  years  (1876  and  1877) 

30 

83 

133 

162 

408 
71 

9 
21 
36 
33 

99 

7 

70  per  cent. 

74 

73 

80 

90 

4  A  moment's  consideration  of  these  facts— indeed,  I  think 
the  question  may  be  considered  as  settled — will  carry  the 
conviction  that  increasing  experience  has  been  accompanied 
by  diminishing  mortality. 

'  In  speaking  of  ovariotomy  in  this  hospital,  and  in  preparing 
the  preceding  tables,  I  have  dealt  with  my  own  work  alone. 
For  many  years,  with  an  occasional  rare  exception,  I  did  all 
these  operations.  And  in  connection  with  the  evidently  in- 
creased success  attending  them,  it  is  interesting,  just  for  a 
moment,  to  look  back  over  the  many  hesitating  steps  by  which 
we  h^ve  advanced  in  gaining  confidence  in  our  diagnosis,  facility 
in  the  purely  operative  proceedings,  and  the  means  of  meeting 
many  of  the  early  difficulties  of  after-treatment. 

'  And  now,  appearing  here  for  the  last  time  as  the  surgeon 
of  the  hospital,  I  am  glad  to  say  that  neither  my  colleagues  nor 
the  governing  body  of  the  institution  wish  that  my  new  position 
as  consulting  surgeon  should  be  purely  honorary. 

*  If  in  some  such  manner  as  this  I  had  not  been  able  to  keep 


216  ADDRESS   ON  LEAVING   HOSPITAL 

up  my  interest  in  the  work  of  this  hospital,  I  might  have  been 
induced  to  perform  the  duty  of  surgeon  for  some  years  longer, 
but  a  long  while  ago  I  was  deeply  impressed  by  some  remarks 
made  by  Sir  Benjamin  Brodie  on  his  retirement  from  St. 
George's  Hospital,  after  eighteen  years'  service  as  surgeon.  I 
forget  the  exact  words,  but  he  has  reprinted  something  very 
like  them  in  the  conclusion  to  his  Autobiography.  He  says — 
"  It  was  not  without  a  painful  effort  that  I  made  up  my  mind 
to  resign  an  office  to  which  I  had  been  sincerely  attached.  In 
doing  so  I  was  influenced  by  various  considerations.  One  of 
them  was  that  I  began  to  feel  the  necessity  of  diminishing  the 
amount  of  my  labours.  Then  I  had  long  since  formed  the 
resolution  that  I  would  not  have  it  said  of  myself,  as  I  had 
heard  it  said  of  others,  that  I  retained  a  situation  of  such 
importance  and  responsibility  when,  either  from  age  or  from 
indifference,  I  had  ceased  to  be  fully  equal  to  the  duties 
belonging  to  it ;  and  lastly,  when  I  saw  intelligent  and  diligent 
and  otherwise  deserving  young  men  around  me,  waiting  their 
turn  to  succeed  to  the  hospital  appointments,  it  seemed  to  me 
that  there  was  something  selfish  in  standing  longer  in  their 
way,  when,  as  far  as  my  own  mere  worldly  interests  were 
concerned,  I  had  obtained  all  that  I  could  desire." 

'When  I  first  heard  these  sentiments  of  Sir  Benjamin 
Brodie  I  determined  that  if  I  should  ever  be  placed  in  any  like 
position  I  would  do  my  best  to  follow  the  example  set  by  so  wise 
and  good  a  man  ;  and  in  carrying  out  that  determination  now, 
I  trust  that  while  I  am  thus  enabled  to  devote  more  time  and 
attention  to  my  private  practice,  I  shall  still  be  of  some  use  to 
the  suffering  women  in  the  hospital  without  standing  in  the 
way  of  ambitious  and  deserving  juniors,  who  have  worked  long 
and  hard  for  the  position  they  have  now  attained,  and  which  I 
sincerely  hope  they  may  enjoy  for  many  years  to  come.' 

The  next  table  of  ovariotomies  fully  justifies  the  course  that 
I  took,  and  makes  it  clear  that  as  yet  the  patients  have  no 
reason  to  regret  the  change.  It  gives  the  results  of  my  imme- 
diate successors,  Bantock  and  Thornton,  for  the  four  years  after 
my  retirement.  Latterly  our  junior  colleague  Meredith  has 
begun  his  career  as  an  ovariotomist  by  a,  series  of  nine  cases,  all 
successful.  Both  he  and  Thornton  invariably  operate  anti- 
septically,  and,  without  drawing  any  deductions,  it  is  only  right 


PRIVATE  PRACTICE 


217 


to  state  that  their  contribution  to  the  mortality  average  of  the 
year  1881  is  very  small,  the  deaths  after  their  fifty  operations 
being  only  two. 


Year 

Cases 

Recoveries 

Deaths 

Mortality  per  cent. 

1878 

76 

61 

15 

19-73 

1879 

86 

76 

10 

11-62 

1880 

94 

85 

9 

9-57 

1881 

84 

75 

9 

10-7 

340 

297 

43 

13 

The  four  years  from  1878  to  1881  have  been  memorable  to 
me  for  two  reasons,  that  during  them  I  completed,  and  now 
more  than  completed,  a  thousand  cases  of  ovariotomy;  and 
that  I  have  taken  up  the  antiseptic  system  adopted  else- 
where, so  as  to  judge  by  my  own  experience,  not  of  its  general 
scientific  claims,  but  of  the  utility  of  the  Lister  spray  and 
dressings  in  abdominal  surgery. 

My  exclusively  private  practice  began  with  the  888th  case, 
and  in  the  month  of  June  1880  the  number  of  1,000  cases  was 
made  good.  The  table  which  I  annex  notes  in  detail  the  times 
in  which  the  several  series  of  hundreds  were  accumulated  and 
other  matters  connected  with  them  which  have  a  statistical 
interest. 


Dates  of  completion  of  the  successive  hundreds  of  Ovariotomy 
Operations  from  1858  to  1880  : — 


No. 
1 

Dates 

Recoveries 

Deaths 

Cases 

From  Feb.  1858  to  June  1864 

66 

34 

100 

2 

„      June  1864  „   Mar.  1867 

72 

28 

100 

3 

„      Mar.  1867  „  Jan.  1869 

77 

23 

100 

4 

„      Jan.  1869  „  Dec.  1870 

78 

22 

100 

5 

„      Dec.  1870  „  June  1872 

80 

20 

100 

6 

„      June  1872  „  Jan.  1874 

71 

29 

100 

7 

„      Jan.  1874  „  April  1875 

76 

24 

100 

8 

„      April  1875  „   Oct.  1876 

76 

24 

100 

9 

„      Oct.   1876  „  June  1878 

83 

17 

100 

10 

„      June  1878  „  June  1880 

89 

11 

100 

768 

232 

1000 

General  Mortality,  23-2  per  cent.  ;  largest  34,  smallest  11, 
The  whole  time  occupied  wa   22  years  and  live  months. 


218  ADDITIONS   TO    PREVIOUS 

I  have  since  up  to  the  date  of  writing  added  sixty  cases 
with  a  loss  of  four  patients,  of  whom  one  died  of  scarlet  fever, 
eight  days  after  operation,  two  maniacal,  in  part  due  to  inve- 
terate alcoholism,  and  the  fourth  from  primary  haemorrhage 
and  shock. 

The  number  of  my  private  ovariotomy  cases  then  since  1877 
in  the  four  years  tells  up  at  the  time  of  writing  to  173,  and 
among  them  there  were  sixteen  which  ended  fatally,  giving  a 
mortality  of  9 '2  per  cent.,  curiously  corresponding  with  that  of 
my  latter  hospital  work. 

Before  touching  upon  the  question  of  what  influence  the 
so-called  '  antiseptic  precautions '  or  details  of  the  Listerian 
method  have  had  upon  my  practice,  I  will  explain  precisely 
what  the  additions  or  changes  have  been,  and  what  modifica- 
tions of  treatment  it  has  induced  me  to  make. 

Long  before  Mr.  Lister  had  tried  any  of  his  methods, 
indeed  from  the  very  beginning  of  my  practice  of  ovariotomy, 
I  had  insisted  upon  all  possible  care  in  protecting  patients 
before,  during,  and  after  operation  from  all  the  known  causes 
of  excessive  mortality,  and  I  took  unusual  precautions  against 
any  risk  of  contagious  or  infectious  disease  being  communicated 
to  a  patient,  and  against  the  entrance  from  without,  or  the 
development  from  within,  of  anything  which  could  set  up  trau- 
matic fever  or  blood-poisoning.  I  contended  that  obstetrics 
and  operative  gynaecology  should  seldom  be  permitted  in  the 
same  building,  or  by  the  same  surgeon  in  private  practice ;  and 
that  such  an  operation  as  ovariotomy  should  never  be  performed 
where  patients  with  uterine  cancer,  or  offensive  discharges  of 
any  kind,  may  pollute  the  place.  In  1875,  a  separate  branch 
of  the  Samaritan  Hospital  was  opened,  and  since  that  year 
the  surgical  wards  have  been  much  freer  from  such  sources 
of  clanger.  The  good  effects  of  this  change  were  noted  before 
other  antiseptic  measures  were  insisted  on.  And  cleansing  or 
purification  of  the  ward  or  room,  of  everything  about  the 
operating  table  and  bedding,  of  the  patient  herself  and  the 
j^arts  near  the  seat  of  operation,  of  the  surgeon,  assistants,  and 
nurses,  and  of  all  the  instruments,  sponges,  and  water  used,  had 
gradually  become  more  complete  before  carbolic  acid  was  used, 
or  any  antiseptic  precaution  added  to  those  adopted  before 
1878. 


ANTISEPTIC   PRECAUTIONS.  219 

As  the  material  for  tying  vessels  and  uniting  the  wound,  the 
same  pure  twisted  silk,  unmixed  with  any  vegetable  fibre, 
which  I  have  trusted  to  for  about  twenty  years  has  been  used. 
1  have  hardly  ever  tried  catgut ;  and  after  trial,  have  abandoned 
whipcord,  hempen  ligatures,  silver,  iron  and  platinum  wire, 
horsehair  and  other  materials.  Various  forms  of  quilled  and 
twisted  sutures  have  also  been  tried  and  abandoned.  But  since 
1878,  all  the  silk  for  ligatures  and  sutures  has  been  soaked 
before  use  in  a  5  per  cent,  solution  of  carbolic  acid  or  phenol. 
I  have  not  boiled  the  silk,  as  Billroth  and  others  have  done. 

Dry  dressing  of  the  wound  has  been  continued ;  but  in 
place  of  the  pads  formerly  used,  of  5  per  cent,  of  oil  of  tar  with 
95  per  cent,  of  chalk,  either  thymol  or  iodoform  gauze,  or  cotton 
pads  charged  with  borax  or  phenol,  have  been  used.  These  are 
more  comfortable  to  the  patient,  and  are  better  absorbents  of 
moisture.  As  a  rule,  they  are  not  touched  before  the  seventh 
or  eighth  day,  when  the  sutures  are  removed,  and  the  wound  is 
almost  invariably  found  to  be  completely  united. 

The  two  most  important  additions  to  previous  antiseptic 
precautions  are,  first,  carbolising  the  sponges  and  instruments, 
and  secondly,  the  use  of  the  spray.  I  had  long  insisted  on  the 
great  importance  of  always  using  perfectly  pure  sponges,  and  I 
believe  this  object  is  more  perfectly  attained  by  soaking  them 
in  a  carbolised  solution  after  washing,  than  by  washing  alone. 

After  an  operation,  I  continue  my  old  plan  of  keeping  the 
cleansed  sponges  in  a  weak  solution  of  sulphurous  acid.  And 
during  the  operation,  in  addition  to  washing  in  pure  water, 
every  sponge  before  use  is  wetted  with  a  2  to  3  per  cent, 
solution  of  carbolic  acid  or  absolute  phenol.  Soft,  clean  linen 
cloths,  wetted  with  a  warm  solution  of  phenol,  may  be  used  to 
lessen  the  number  of  sponges  required;  and  nurses  must  be 
cautioned  not  to  put  any  of  the  soiled  sponges  into  the  solution 
until  after  they  have  been  washed,  otherwise  albumen  may  be 
so  coagulated  as  to  prevent  thorough  cleansing.  As  nurses 
often  fall  into  this  error,  it  is  well  to  have  two  or  three  different 
sets  of  sponges,  all  carefully  numbered,  kept  separate  for  the 
successive  steps  of  the  operation. 

Nearly  all  the  instruments  used  in  ovariotomy  may  be  pro- 
tected from  rust  by  a  coating  of  nickel.  They  are  then  more 
easily  and  I  horoughly  cleaned  after  use,  and  the  cleaned  instru- 


220  EECENT   MODIFICATIONS   OF 

ments  should  be  placed  before,  and  replaced  during,  the  opera- 
tion in  trays  or  dishes  filled  with  a  warm  solution  of  phenol. 

These  additional  precautions  as  to  sponges,  silk,  and  instru- 
ments, I  believe  to  be  really  important.  I  feel  still  doubtful 
about  the  spray.  '  Striving  to  better,  oft  we  mar  what's  well.' 
In  prolonged  operations,  I  have  had  reason  to  fear  that  its 
chilling  effect  upon  the  patients  has  been  injurious.  But  I 
have  never  once  seen  any  other  ill  effect  which  I  could  attribute 
to  it,  nor  anything  like  carbolic  poisoning.  The  misty  cloud 
occasionally  obscures  the  field  of  operation,  but  not  to  any 
serious  extent,  and  it  is  always  easy  to  protect  the  peritoneal 
cavity  against  the  continued  action  of  the  spray  by  a  large 
warm  sponge.  After  a  few  trials  I  gave  up  thymol  spray  as 
useless,  and  for  more  than  a  year  past  have  used  a  spray  of 
absolute  phenol  of  a  strength  of  one  in  forty.  And  this  I  con- 
tinue to  use,  believing  it  to  be  safer  than  the  irrigation  or 
sponging  proposed  as  substitutes,  although  I  fully  admit  that 
we  require  a  far  greater  number  of  trustworthy  experiments,  or 
of  comparative  observations  made  under  similar  conditions  with 
and  without  spray  than  have  yet  been  made  known,  before  we 
can  receive  any  satisfactory  answer  to  the  questions  whether  car- 
bolised  vapour  or  air  can  destroy  or  render  innocuous,  infective 
or  putrefactive  substances  or  germs  floating  in  the  air ;  or  what 
is  the  share  which  the  spray,  among  other  additional  antiseptic 
precautions,  has  had  in  obtaining  the  better  results  which 
have  undoubtedly  accompanied  their  combined  employment. 

On  carefully  going  over  the  notes  of  all  the  cases  to  ascer- 
tain if  the  smaller  mortality  in  those  treated  antiseptically 
could  be  due  to  any  other  cause,  the  only  modification  in  the 
mode  of  operation  which  calls  for  further  remark  is  the  very 
much  more  frequent,  almost  constant,  employment  of  the 
m£ra-peritoneal  treatment  of  the  pedicle  since  the  trial  of  the 
antiseptic  system  was  begun.  Before  that  time,  the  extra- 
peritoneal treatment  had  been  by  far  the  more  successful  in  my 
practice.  When  comparing  the  results  of  the  two  methods  at 
the  College  of  Surgeons  in  June  1878,  I  showed  that  of  627 
eatfra-peritoneal  cases,  130  had  died,  or  20*73  per  cent.,  while 
of  157  intra  -peritoneal  cases,  60  died,  or  38*2  per  cent.,  the 
mortality  with  the  ligature  having  been  nearly  double  that  with 
the  clamp.     I  am  quite  sure  that,  as  has  been  suggested,  the 


THE    OPERATION  221 

extra-peritoneal  did  not  represent  the  simple,  and  the  intra- 
peritoneal the  complicated,  cases.  The  difference  was  simply 
that  of  long  or  short  pedicle.  Whenever  the  pedicle  was  long 
enough,  I  used  to  employ  a  clamp  whatever  might  be  the  com- 
plications of  the  case  ;  and  in  short  pedicles  I  used  the  ligature 
or  cautery,  whether  the  case  was  otherwise  simple  or  the  reverse. 
To  my  mind,  one  great  merit  of  the  antiseptic  system  is  that  it 
has  made  the  m^ra-peritoneal  method,  which  was  formerly 
the  less,  now  the  more  successful  method  of  dealing  with  the 
pedicle.  Formerly,  septic  changes,  which  are  now  scarcely  ever 
observed,  frequently  took  place  in  or  about  the  tied  pedicle, 
and  the  many  disadvantages  of  the  eatfra-peritoneal  method, 
which  were  only  counterbalanced  by  its  greater  success,  have 
no  longer  to  be  endured. 

Another  great  gain  from  the  antiseptic  system  is  that 
drainage  of  the  peritoneal  cavity  is  now  scarcely  ever  necessary. 
In  the  paper  which  I  brought  before  the  Medical  and  Chirurgical 
Society  on  completing  800  cases,  I  contended  that  drainage 
should  only  be  an  exceptional  practice.  But  I  did  not  then 
imagine  that  it  could  be  almost  entirely  discarded.  I  can 
now  say  that  I  have  not  drained  one  case  in  which  antiseptic 
precautions  have  been  taken;  and  on  looking  back,  I  cannot 
believe  that  there  are  more  than  two  in  which,  if  a  drainage 
tube  had  been  used,  it  could  have  been  useful.  The  simple 
explanation  is,  that  the  mixture  of  blood,  other  fluids,  and  air 
left  in  the  peritoneal  cavity,  or  oozing  into  it  after  operation, 
formerly  went  through  putrefactive  changes,  and  if  not  drained 
off  produced  septicemia,  whereas  now  no  putrefaction  takes 
place,  and  absorption  is  quite  harmless. 

It  will  be  gathered  from  these  remarks  that  the  chief  modi- 
fications in  my  practice  have  been  the  use  of  the  carbolic  spray 
during  the  operation,  the  soaking  of  the  sponges,  silk,  and 
instruments  in  a  solution  of  the  acid,  tying  the  pedicle,  and 
leaving  it  in  the  cavity,  and  the  disuse  of  drainage  tubes  even 
in  unpromising  cases. 

I  now  turn  to  the  question  of  results.  I  am  convinced  that 
by  the  use  of  antiseptics,  especially  of  phenol,  those  patients 
who  have  recovered  have  suffered  much  less  from  fever,  while 
convalescence  has  been  more  rapid  than  it  used  to  be. 
Formerly,  temperatures  of  100°  to  103°  were  usual,  and  104° 


22*> 


RESULTS    OF 


to  107°  not  very  uncommon.  And  the  head  was  cooled  by  ice 
in  at  least  half  the  cases.  Now,  cold  to  the  head  is  scarcely 
ever  thought  of,  certainly  not  used  in  one  case  in  twenty,  and 
a  temperature  of  102°  is  rare.  Eecovery  with  a  temperature 
which  never  rises  above  100°  is  the  rule. 

This  alone  is  an  important  step  in  advance,  especially  as 
it  affects  the  well-being  of  the  great  majority  of  patients,  and 
for  those  in  hospitals  lessens  considerably  the  cost  of  their 
maintenance. 

The  table  which  I  now  offer  may  help  in  the  examination  of 
the  question  of  the  influence  of  the  antiseptic  system  on  my 
practice,  though  it  shows  at  the  same  time  how  complex  the 
problem  is,  and  how  much  more  evidence  is  wanted  before  it 
can  be  cleared  up. 

Table  of  Cases  of  Ovariotomy,  showing  the  Mortality  before  and 
after  Antiseptics. 


Cases 

Deaths 

Mortality  per  cent. 

Hospital.     Years  1876-77     . 

71 

7 

9-8 

Private.     Same  time     . 

81 

22 

27-1 

Hospital  and  private  cases  toge- 

ther 1876-77     .... 

152 

29 

18-4 

165  private  cases  from  Dec.  1873 

to  Dec.  1877       .... 

165 

42 

25-4 

165  private  cases  from  Jan.  1878 

to  Dec.  1881       .... 

165 

16 

9-6 

The  first  and  last  entries  would  almost  settle  the  whole 
matter  negatively  if  they  stood  alone.  The  series  of  165  cases 
done  antiseptically  cannot  be  said  to  be  better  than  the  71 
hospital  cases  done  according  to  my  former  custom.  Taken 
together  they  only  make  it  evident  that  under  given  conditions 
ovariotomy  can  be  practised  as  successfully  one  way  as  the 
other.  But  if  I  compare  the  private  cases  which  I  did  during 
the  two  last  years  of  my  hospital  work  with  the  cases  which 
came  after  them,  the  -contrast  is  very  striking.  I  had  81  cases 
with  22  deaths,  a  mortality  of  27*1  per  cent.,  and  this  would 
make  the  benefit  of  antiseptics  seem  to  be  as  much  as  17  per 
cent.  Putting,  however,  the  whole  practice  of  those  two  years 
together,  hospital  as  well  as  private  cases,  the  advantage  became 
a  trifle  less  than  9  per  cent.  Still,  as  all  the  circumstances  of 
the  two  series  were  so  different,  they  afford  no  real  ground  for 


PRIVATE    PRACTICE  223 

forming  a  judgment.  I  test  the  matter  yet  further,  and  take  the 
165  cases  which  I  operated  on  under  the  old  system  before  1878, 
and,  placing  their  results  against  those  which  came  out  of  the 
succeeding  165  cases,  it  leaves  a  balance  of  about  15  per  cent, 
apparently  in  favour  of  antiseptics.  If  there  were  no  other 
points  to  be  considered  beside  those  involved  in  mere  figures,  a 
difference  of  mortality  to  this  extent  would  be  decisive.  But 
in  the  first  place  the  patients  have  all  had  the  advantages 
belonging  to  a  position  in  life  above  that  of  hospital  cases. 
Then  the  abandonment  of  the  clamp  and  the  use  of  the  liga- 
ture with  the  intra-peritoneal  treatment  of  the  pedicle  took 
place  at  the  time  of  the  other  change  of  dressing  and  the  use 
of  the  spray ;  and  I  have  never  put  a  drainage  tube  into  any 
one  of  the  wounds.  It  must  be  remembered,  too,  that  I  have 
been  free  from  all  but  the  most  casual  contact  with  hospital 
influences,  have  never  attended  a  post-mortem,  never  carried 
about  with  me  the  infections  picked  up  in  general  practice,  and 
having  had  fewer  persons  present  at  my  operations  have  elimi- 
nated a  great  part  of  an  incalculable  source  of  danger.  Again, 
it  appears  by  my  reports  that  four  of  my  last  sixteen  deaths 
were  caused  by  septicaemia,  so  that  antisepticism  has  not 
abolished  this  plague  of  abdominal  surgery. 

On  the  other  hand,  these  four  deaths  are  an  improvement 
on  the  seven  hospital  deaths,  five  of  which  resulted  from  septi- 
caemia, one  from  peritonitis,  and  the  seventh  from  some  cause  not 
recorded,  but  five  days  after  operation,  which  looks  suspicious. 
The  six  verified  deaths  make  nearly  9  per  cent,  from  septic 
causes.  Now  though  it  would  not  be  quite  fair  to  say  that  with- 
out antiseptics  I  should  have  had  a  similar  mortality,  from  that 
cause,  in  my  165  post-hospital  cases,  which  would  have  raised  the 
deaths  from  16  to  30,  because  the  patients  were  not  similarly 
situated,  it  is  possible  that  I  should  have  seen  more  of  some 
septic  disease. 

As  I  have  before  said,  I  never  felt  any  inconvenience  myself, 
nor  have  I  seen  any  of  my  patients  suffer  from  carbolic  poison- 
ing. Still,  as  other  surgeons  have  encountered  that  double 
objection  to  the  spray,  it  must  be  taken  into  account,  as  well  as 
the  depressing  influence  of  the  cold  on  a  sick  woman  prostrated 
by  anaesthetics,  and  the  inconvenience  caused  by  its  interference 
with  light. 


224  DR.    KEITH'S    PRACTICE 

The  question  of  what  proportion  of  my  late  results  may  be 
due  to  following  the  details  of  Lister's  antiseptic  plans  remains 
undecided.  They  certainly  have  not  brought  me  to  the  point 
of  seeing  no  deaths  from  septicaemia  as  promised  by  some  of 
their  enthusiastic  promoters,  nor  have  they  advanced  my  success 
in  operating  beyond  what  was  attained  without  it ;  but  they 
seem  to  have  made  convalescence  more  easy  and  rapid,  and  to 
have  reduced  the  number  of  deaths  from  septic  disease,  and 
perhaps  might  have  prevented  every  one  of  the  deaths  among 
my  last  seventy-one  hospital  cases,  for  not  one  of  these  suffered 
from  any  accidental  causes  of  death  such  as  took  off  at  least 
twelve  of  the  sixteen  who  died  among  my  antiseptic  cases,  and 
are  almost  always  met  with  in  any  equal  number  of  patients. 

Eesuming  our  survey  of  the  history  and  progress  of  ovari- 
otomy since  its  revival  in  Great  Britain,  I  must  refer  to  a  letter 
received  from  Dr.  Keith  on  the  27th  of  October,  1881,  in  which 
he  informs  me  that  his  number  of  operation  cases  was  then 
381.  Of  these  340  recovered  and  41  died,  showing  a  death 
rate  of  10*76  per  cent.  But  the  mortality  has  gradually  dimin- 
ished, and  of  the  last  140  cases  135  have  clone  well.  This 
presents  the  astonishing  result  of  a  loss  of  only  3*57  per  cent. 

He  retains  his  preference  for  the  cautery  and  says — '  In  the 
treatment  of  the  pedicle  the  best  results  by  far  are  still  got  by 
the  cautery.  I  much  prefer  the  cautery,  and  think  it  the  most 
perfect  way.  Of  the  last  120  cautery  cases  there  were  only  two 
deaths  (1*6  per  cent.)  ;  one  of  these  from  cardiac  embolism  in 
the  third  week,  the  other  from  supposed  carbolic  acid  poison- 
ing. I  have  also  removed  at  the  vaginal  junction  nine  large 
uterine  fibre  -cysts  or  soft  fibroids.  Of  these  eight  recovered.  Of 
nearly  400  operations  there  have  been  only  two  mistakes  of 
diagnosis.  These  were  cases  of  fibro-cystic  tumours  of  the 
uterus,  and  not  ovarian  tumours  as  was  supposed.  In  both 
the  operation  was  gone  on  with,  and  both  patients  did  well.' 

Dr.  Keith  adds  that  '  his  son  has  recently  done  five  cases  ; 
all  recovered,'  and  I  most  cordially  wish  him  the  same  amount  of 
success  that  has  rewarded  the  skill  and  judgment  of  his  father. 

We  have  now  to  follow  the  advance  of  the  operation  in 
France,  Belgium,  Germany,  Russia,  Italy,  and  Spain,  and  in 
America  and  our  colonies,  although  any  such  review  must  neces- 
sarily be  brief  and  imperfect. 


OVAEIOTOMY   IN  FRANCE  225 

In  France,  ovariotomy  made  but  tardy  progress ;  nor  was 
this  to  be  wondered  at,  when  we  find  a  man  like  Velpeau 
(<  Gazette  des  Hopitaux,'  ]  847,  p.  420)  writing  in  this  fashion  : 
*  Ce  sont  de  telles  temerites  qu'il  faut  repousser  de  toutes  nos 
forces,  parcequ'elles  ne  sont  que  preuve  de  folie.  II  est  heureux 
pour  l'honneur  de  notre  art  et  de  notre  nation  que  rien  de 
semblable  ne  se  passe  ici.  C'est  en  Amerique,  c'est  en  Angle- 
terre,  c'est  en  Allemagne  aussi  qu'on  a  vu  faire  de  telles  folies. 
Tous  les  ans,  tous  les  mois,  les  journaux  etrangers  nous 
apportent  la  nouvelle  de  pareilles  tentatives,  tout  le  monde 
les  fait,  et  chose  inouie,  c'est  de  les  voir  faire  par  des  gens  d'un 
grand  merite.'  Notwithstanding  Cazeaux's  spirited  and  ener- 
getic advocacy  at  a  meeting  of  the  Academie  de  Medicine,  in 
1856,  the  operation  was  condemned;  the  papers  of  Charles 
Bernard  in  the  '  Archives  generales  de  Medecine,'  of  the  same 
year,  and  a  very  able  paper  by  Dr.  Worms,  in  the  '  Gazette 
hebdomadaire,'  1860,  had,  however,  a  better  result.  Dr. 
Worms's  paper  was  founded  principally  upon  a  careful  examina- 
tion of  some  of  my  own  early  cases.  He  took  the  precaution  of 
writing  to  the  medical  attendants  of  the  patients,  in  order  to 
ascertain  their  condition  from  the  time  of  operation  up  to  the 
date  of  his  paper,  and  this  able  and  spirited  advocacy  attracted 
very  general  attention  in  France.  Perhaps  its  most  important 
effect  was  to  induce  M.  Nelaton  to  visit  England  for  the 
purpose  of  witnessing  the  operation,  and  carefully  studying  its 
details.  He  was  herein  1862,  and  witnessed  several  operations. 
He  assisted  me  at  one  very  complicated  case,  which  terminated 
successfully,  and  was  much  interested  in  another  where  tetanus 
proved  fatal.  On  his  return  to  Paris,  he  operated  himself,  and 
published  a  classical  clinical  lecture,  from  which  may  be  dated 
the  revival  of  ovariotomy  in  France.  Kceberle,  of  Strasburg, 
performed  his  first  operation  in  1862,  which  was  also  the  date 
of  Nelaton's  first  operation.  It  had  certainly  been  performed  in 
France  before  Nelaton's  visit  to  England.  The  first  case  was 
in  1844,  by  a  country  surgeon,  Dr.  Woyerkowski,  of  Quingez. 
This  case  may  be  looked  upon  rather  as  an  accidental  than  an 
intentional  ovariotomy.  The  next  case  was  in  1847.  The 
patient  had  undergone  fifty-two  tappings,  when  another  country 
surgeon,  M.  Vaullegeard,  of  Conde-sur-Noireau,  with  remark- 
able ability  and  courage,  successfully  removed  a  tumour  which 

Q 


226  OVARIOTOMY   IN   BELGIUM 

weighed  about  seventeen  pounds.  The  patient  recovered  perfect 
health,  although  she  died  five  years  after  of '  miliary  fever.' 
After  this,  until  Nelaton's  visit  to  England,  the  history  of 
ovariotomy  in  France  consists  of  eight  unsuccessful  operations 
by  Bach,  Maisonneuve,  Hergott  et  Michel,  Jobert,  Boinet, 
Kichard,  Dernarquay,  and  Sedillot.  Since  1862,  the  example 
of  Nelaton  in  Paris,  and  the  influence  of  Boinet,  followed  by 
the  many  successful  operations  of  Pean,  have  done  much  to 
legitimize  the  operation  of  ovariotomy  in  the  capital  of  France ; 
but  the  far  larger  experience  of  Koeberle,  of  Strasburg,  has 
probably  had  even  a  still  greater  effect. 

I  have  not  yet  been  able  to  obtain  the  latest  results  of  the 
practice  of  my  friend  Koeberle,  but  Eustache,  of  Lille,  reports 
him  to  have  had  more  than  320  operations  early  in  1881.  It 
seems  to  be  very  difficult  to  obtain  accurate  information  of 
what  has  been  done  recently  in  this  part  of  surgery  in  France. 
In  the  work  of  Eustache,  which  is  the  latest  published  on  the 
subject,  the  figures  are  deficient  and  tell  us  nothing  that  has 
taken  place  within  the  last  two  or  three  years  of  increasing 
activity,  and  better  success.  It  is  useless,  therefore,  to  quote 
them.  But  Pean  has  obligingly  sent  me  his  report  up  to  the 
month  of  October  1881.  His  gastrotomies  altogether  amount 
to  449.  Three  hundred  and  six  of  these  were  for  the  removal 
of  ovarian  cysts,  with  245  recoveries  and  61  deaths.  But  it  is 
the  same  with  Pean  as  with  most  other  surgeons.  His  latest 
work  is  his  best,  for  out  of  the  last  100  ovariotomies  there  have 
been  only  fourteen  bad  results  ;  and  curiously  enough,  exactly 
seven  in  each  of  the  two  last  fifties. 

I  believe  I  was  the  first  to  perform  ovariotomy  in  Belgium, 
in  July  1865,  in  the  chief  hospital  at  Brussels,  upon  a  patient 
of  Dr.  Deroubaix,  in  the  presence  of  a  large  number  of  dis- 
tinguished Belgian  surgeons.  The  operation  was  completed  so 
easily  that  it  was  hoped  the  example  would  soon  be  followed 
in  Belgium  ;  but,  unfortunately,  the  patient  died  a  week  after 
operation,  as  it  was  believed  from  influences  almost  inseparable 
from  a  large  general  hospital.  Still,  as  the  result  was  unsuc- 
cessful, it  probably  retarded  for  a  time  the  progress  of  ovari- 
otomy in  Belgium.  The  first  successful  case  in  that  country 
was  by  a  pupil  of  my  own,  Dr.  Boddaert,  of  Grhent,  who  pub- 
lished accounts  of  the  case,  very  kindly  attributing  his  success 


OVARIOTOMY   IN  SWITZERLAND  227 

to  the  minuteness  with  which  he  followed  every  detail  of  the 
operation  as  he  had  seen  it  performed  by  me  in  England.  I 
had  a  successful  case  in  Ghent  in  1871,  and  Dr.  Boddaert 
had  two  successful  cases  in  1872.  These  four  cases,  I  am  in- 
formed, were  the  only  instances  of  success  out  of  about  twenty 
operations  in  that  country  up  to  that  time.  Dr.  Deroubaix  was 
in  England  in  1872,  with  the  express  object  of  perfecting  his 
knowledge  of  the  various  steps  of  the  operation,  and  there  can 
be  little  doubt  that  he  has  by  this  time  reaped  the  reward  of 
his  intelligence  and  zeal.  I  have  no  more  general  information 
as  to  what  has  been  done  in  Belgium,  and  Dr.  Boddaert  assures 
me  that  it  would  be  impossible  to  obtain  accurate  statistics  for 
that  country,  as  many  cases  remain  unpublished.  His  personal 
experience,  however,  to  the  end  of  1881  amounts  to  this,  and 
it  is  most  worthy  of  congratulation :  21  cases  with  12  re- 
coveries and  9  deaths  before  antiseptics ;  27  cases  since  anti- 
septics, with  25  recoveries  and  only  2  deaths. 

I  led  the  way  to  the  practice  of  ovariotomy  in  Switzerland 
by  operating  on  a  lady  at  Zurich  in  July  1864,  who  recovered 
perfectly  well  and  has  enjoyed  good  health  up  to  the  present 
time.  Professor  Liicke,  of  Berne,  who  is  now  at  Strasburg, 
took  it  up  in  1866,  and  since  that  time  he  has  had  some 
thirty  or  more  imitators,  who  have  upon  the  whole  worked 
with  a  very  commendable  success.  My  friend  Dr.  Kocher,  of 
Berne,  has  very  diligently  collected  for  me  the  particulars  of 
nearly  all  the  operations  that  have  been  done  in  Switzerland, 
and  has  favoured  me  by  sending  most  of  the  letters  of  his 
correspondents,  so  that  my  information  is  of  the  most  authentic 
kind.  In  all  I  have  accounts  of  231  cases,  the  recent  ones 
having  been  treated  according  to  Lister's  system.  The  results 
are  177  recoveries  and  54  deaths,  a  mortality  of  23*3  per  cent. 
These  231  cases  are  divided  between  some  25  operators,  several 
of  whom  have  only  done  a  single  case.  Others  have  had  as 
many  as  six  or  ten  operations  ;  Professor  Socin,  of  Basle,  Dr. 
Dupont,  of  Lausanne,  and  Professor  Julliard,  of  Geneva,  eleven 
and  twelve.  Dr.  Kiihn,  of  St.  Gallen,  reports  22  cases  with  3 
deaths,  and  Professor  Bisehoff,  of  Basle,  33  cases  of  ovariotomy, 
8  of  which  were  double,  with  7  deaths  from  peritonitis,  all 
having  been  performed  under  carbol  spray  and  with  Lister  dress- 
ing.    Four  were  cases  of  castration  (Battey),  both  ovaries  being 

Q  2 


228  OVARIOTOMY   IN   GERMANY 

removed,  and  all  these  recovered.  Professor  Miiller,  of  Berne, 
has  done  the  operation  34  times,  with  a  loss  of  5  patients  only, 
and  Dr.  Kocher  himself  heads  the  list  with  47  cases  and  a 
mortality  of  no  more  than  9*5  per  cent,  since  he  adopted  the 
antiseptic  treatment.  One  of  the  fatal  cases  was  most  deplor- 
able, as  showing  that,  in  spite  of  the  most  exact  precautions,  the 
life  of  a  patient  and  the  reputation  of  an  operator  are  at  the 
mercy  of  thoughtless,  if  not  culpable,  imprudence.  According 
to  custom,  the  sponges  were  counted  before  and  were  counted 
again  after  the  operation.  They  were  fixed  in  number  and  not 
one  was  wanting.  But  a  sponge  was  left  in  the  abdomen,  and  the 
sister  accused  an  assistant  of  having  torn  a  sponge  in  two 
during  the  operation.  A  similar  folly  was  just  stopped  in 
time  here  not  long  ago,  proving  that  a  supplement  to  my 
caution  as  to  number  and  counting  is  as  necessary  as  the 
original  test.  The  sponges  should  not  only  be  counted  but 
identified. 

In  Germany,  until  quite  recently,  ovariotomy  was  scarcely 
either  talked  or  thought  of.  In  1819  and  1820  operations 
by  Chrysmar,  and  in  1820  by  Dzondi,  only  served  to  bring  the 
operation  into  discredit.  Dieffenbach,  who  had  long  con- 
demned the  operation,  operated  in  1826.  He  met  with  great 
difficulty  in  arresting  the  bleeding,  but  his  operation  was 
crowned  with  success.  Martini,  Eitter,  and  others  followed 
Dieffenbach's  example,  but  with  so  little  success  that,  from 
1826  to  1850,  only  three  recoveries  were  obtained  in  twenty 
operations ;  and,  of  eighteen  completed  operations,  five  proved 
fatal.  Accomplished  surgeons — Langenbeck,  Heyfelder,  Ki- 
wisch,  Schulz,  Siebold,  and  Scanzoni — tried  what  they  could 
do,  but  failed ;  and  it  is  not  surprising  that,  for  several  years, 
the  operation  ceased  to  be  practised.  In  1866  my  volume  on 
i  Diseases  of  the  Ovaries '  was  translated  into  German  by 
Kiichenmeister.  Billroth,  who  had  assisted  me,  and  who  had 
carefully  studied  the  whole  subject,  began  to  use  his  great 
influence  with  his  countrymen  to  promote  the  general  accept- 
ance of  the  operation.  Nussbaum,  of  Munich,  came  twice  to 
England,  assisted  me  several  times,  and  has  performed  ovariotomy 
more  frequently  than  any  other  German  surgeon  ;  and  Spiegel- 
berg  entered  upon  a  long  career  of  successful  operations. 
Grenser,  of  Dresden,  made  known  the  results  of  a  long  visit  to 


EAKLY   EXPERIENCE   IN   GERMANY  229 

England  in  an  able  review  of  what  he  saw  here ;  and  ovariotomy 
has  undoubtedly  now  become  generally  accepted  by  the  profes- 
sion in  Germany  as  one  of  the  triumphs  of  surgery. 

The  work  of  Grenser  was  published  in  1870,  entitled  '  Ova- 
riotomy in  Grermany ' ;  and,  as  a  workman  feels  the  approval 
of  his  fellow-workmen,  next  to  the  consciousness  of  saving  life, 
as  his  highest  reward,  it  was  with  great  satisfaction  that  I  read 
the  dedication  to  me,  '  As  a  recognition  of  great  services  to 
science  and  mankind.'  He  gives  the  total  number  of  com- 
pleted cases  of  ovariotomy  in  Grermany,  up  to  the  end  of  1869, 
as  one  hundred  and  twenty-nine,  seven  uncompleted  operations, 
and  ten  cases  of  mistaken  diagnosis.  Of  the  completed  cases, 
sixty-two  recovered,  and  sixty-seven  died.  The  results  of  the 
three  operators  who  had  performed  the  greatest  number  of 
operations  were  somewhat  better  than  the  mortality  of  the 
whole  one  hundred  and  twenty-nine  cases.  Nussbaum  had 
eighteen  recoveries  and  sixteen  deaths ;  Spiegelberg  ten  re- 
coveries and  six  deaths;  Stilling  eight  recoveries  and  nine 
deaths — a  total  of  thirty-six  recoveries  and  thirty-one  deaths. 
These  results,  though  very  far  from  satisfactory,  are  a  great 
deal  better  than  those  mentioned  by  Dutoit,  who  published,  in 
1864,  tables  of  the  results  of  ovariotomy  in  England,  Grermany, 
and  France,  giving  the  results  of  the  operation  in  Germany  as 
fifty-one  cases,  of  which  only  thirteen  recovered  and  thirty- 
eight  died.  We  now  know  that  the  results  of  ovariotomy  in 
Germany,  after  the  publication  of  Grenser's  work,  continued  to 
improve  after  1870,  as  they  did  between  the  years  1864  and 
1870.  Billroth,  for  instance,  writing  in  November  1871, 
says :  '  Up  to  the  present  time,  I  am  tolerably  contented  with 
my  results.  I  have  personally  no  reason  for  supposing  that  the 
results  will  be  less  cheering  in  Vienna  than  they  are  in  London. 
Hitherto,  I  have  performed  ovariotomy  nine  times,  and  only 
two  of  the  patients  have  died — a  mortality  of  only  22*02  per 
cent.  The  first  four  cases  recovered  one  after  the  other  ;  then 
two  fatal  cases  occurred,  to  be  followed  again  by  three  reco- 
veries.' Knowing  the  position  which  Billroth  holds  among 
European  surgeons,  I  cannot  refrain  from  quoting  the  following 
passage  from  the  lecture  in  which  the  above  results  are 
stated :  '  After  ovariotomy,  skilfully  performed  according  to 
the  rules  of  art,  recovery  is  the  general  rule,  and  a  fatal  issue 


230  REPORT  BY   OLSHAUSEN 

the  constantly  diminishing  exception.  Comparing  it  with  some 
other  operations,  ovariotomy,  taking  the  mass  of  cases,  is  shown 
by  statistics  to  be  less  dangerous  than  amputation  of  the  thigh, 
disarticulation  of  the  shoulder  and  hip  joints,  or  excision  of  the 
hip  or  knee.  Its  danger  is  about  the  same  as  that  of  amputa- 
tion of  the  arm,  excision  of  the  shoulder,  partial  excision  of  the 
jaw,  lithotomy  in  the  young,  and  similar  operations.  We  must, 
however,  perform  ovariotomy  strictly  according  to  the  rules 
laid  down  by  the  Engish  operators  in  their  classical  works ; 
and  only  after  having  attained  the  same  results  should  we 
venture  practically  to  put  in  force  our  own  ideas,  in  order  to 
improve  upon  these.  I  had  the  good  fortune  to  see  Spencer 
Wells  operate  upon  two  complicated  cases,  and  from  them,  as 
well  as  from  oral  communication  with  this  remarkable  man, 
I  learned  much.  I  constantly  follow  his  precepts,  knowing 
that  he  has  long  since  thoroughly  thought  out  and  tested  all 
that  can  happen  to  myself.  I  shall  willingly  regard  myself 
during  my  lifetime  as  his  scholar  ;  and  contented  shall  I  be  if 
it  falls  to  my  lot,  by  means  of  this  operation,  to  snatch  from 
certain  death  one-half  the  number  of  lives  he  has  been  enabled 
to  save.'  It  would  be  almost  impossible  to  resist  the  gratifica- 
tion— '  laudari  a  viro  laudato  ' — which  any  surgeon  would  feel 
in  republishing  remarks  like  these,  coming  from  such  a  man  as 
Billroth. 

Up  to  the  beginning  of  1877  Olshausen  tabulated  613 
cases  by  Grerman  operators  of  completed  ovariotomy,  with 
353  recoveries,  or  43  per  cent,  of  deaths  and  57  per  cent, 
of  recoveries.  Since  the  adoption  of  the  antiseptic  treatment 
in  Germany,  the  results  obtained  by  Schroeder,  Nussbaum, 
Olshausen,  Esmarch,  and  many  other  German  surgeons  are,  to 
say  the  least,  equal  to  those  announced  in  any  other  country. 

Professor  Schroeder,  of  Berlin,  sends  a  report  of  his  practice 
of  ovariotomy  up  to  October  31,  1881.  It  comprises  276  opera- 
tions, with  39  deaths,  one  case  of  myxoma  of  the  ovary  and 
peritoneum  being  included. 

One  case  of  enucleation,  &c,  in  the  third  hundred  is  not 
included. 

First  hundred 17  deaths 

Second  hundred 18      „ 

Last  seventy-six  ...  4  or  5-26  per  cent. 


OVARIOTOMY   BY   SCHROEDER   AND   NUSSBAUM  231 

Of  excisions  of  uterine  myxomas  intra-peritoneally  treated 
there  were  eleven  recoveries  one  after  the  other.  Two  of  these 
were  very  small  and  removed  during  ovariotomy. 

I  have  received  from  Professor  Nussbaum  the  following 
report  of  his  ovariotomy  practice : — 

<  From  February  26, 1861,  to  October  31, 1881, 1  have  done 
ovariotomy  332  times,  with  83  deaths.  Fourteen  were  cases 
of  double  ovariotomy,  and  I  must  beg  it  to  be  understood  that 
all  the  patients  were  in  such  an  advanced  state  of  disease  that 
they  must  have  died  without  operation. 

Of  my  first    100  cases 37  died 

„      second      „  26    „ 

„      third        „  .        ....  16    „ 

„      last      32  cases 4    „ 

4  Before  using  Lister's  antiseptic  system  I  had  made  84 
ovariotomies,  with  a  loss  of  38  cases. 

1  Since  adopting  the  spray  I  have  had  248  operations  and 
only  45  deaths  (18*14  per  cent.). 

'  History  of  my  332  Ovariotomies. 

'  My  first  five  patients  died,  and  I  was  so  disheartened  that 
I  left  off  operating.  In  1864  I  went  to  London,  and  there 
learnt  from  Spencer  Wells  the  toilette  of  the  peritoneum. 

'The  first  78  cases  were  treated  with  the  clamp,  extra- 
peritoneal, and  35  died.  In  6  I  tried  vaginal  drainage,  and 
3  died.  In  62  of  the  remaining  248  I  followed  the  practice 
of  Kceberle,  with  19  deaths.  In  168  the  pedicle  was  tied  with 
catgut,  cauterised  with  the  thermo-cautere  and  dropped  in, 
and  there  were  26  deaths.  All  these  cases  were  done  under 
Lister's  spray  and  had  his  dressings. 

'  Remarks. — Eleven  of  the  women  operated  on  have  since 
had  children. 

'  325  were  cases  of  cystoid  ovarian  tumours.  In  seven  cases 
the  ovaries  were  removed  on  account  of  haemorrhage  and 
fibroid  tumours  of  the  uterus ;  four  died. 

'  The  causes  of  the  83  deaths  were  in 

'  20  collapse. 

'  44  septicaemia. 


232 


OVARIOTOMY   BY   OLSHAUSEN 


'  19  various — pleuritis,  pneumonia,  marasmus,  typhus,  diph- 
theria, haemorrhage. 

'  With  the  exception  of  the  castration  cases  the  smallest 
mass  removed  weighed  65  grammes  and  was  infiltrated  with 
pus  ;  the  largest  weighed  51  kilo.  (102  pounds).  This  patient 
died  after  20  hours,  without  having  secreted  one  drop  of  urine. 

'The  youngest  patient  was  17  years  of  age  and  the  oldest 
75.     She  recovered  without  fever. 

'  The  case  of  a  girl,  four  years  old,  from  whom  I  removed 
an  ovary  from  a  strangulated  hernia,  has  not  been  counted  as 
an  ovariotomy.  The  shortest  stay  in  the  hospital  was  14  days, 
and  the  longest  five  months. 

'  One  of  the  cases  treated  with  the  clamp  on  the  extra-peri- 
toneal system,  and  22  done  with  the  spray  and  antiseptic 
management,  recovered  without  any  rise  of  temperature  or 
feeling  of  illness. 

'  The  most  serious  complications  met  with  were  cancer, 
adhesions  of  the  intestines  and  to  the  diaphragm,  identification 
of  the  intestine  with  the  cyst,  and  one  case  in  which  a  part  of 
the  ureter  was  cut  away  was  cured  by  making  an  artificial  ureter.' 

I  also  herewith  give  a  translation  of  part  of  a  letter  re- 
ceived in  November  1881  from  Professor  Olshausen,  of  Halle. 

1  The  ovariotomies  I  have  performed  antiseptically  are — 


From  July  29  to  December  31,  1876 
In  the  year    .  .  1877 

1878 
1879 
1880 
And  to  October     .        .        .     1881 

In  all,  from  July  29, 1876,  to  October  24, 1881 


8  cases 
16 
33 
23 
29 
32 

141  cases 


'  All  these  operations  were  done  under  carbolic  acid  spray. 
Of  the  cases  operated  on  20  died  =  14*2  per  cent.  Another 
died  of  carcinoma  40  days  after  the  operation. 

'  The  causes  of  death  were — 

Shock 5  cases 

Peritonitis,  septicaemia 8     „ 

Ileus  on  the  2nd  and  30th  day 2     „ 

Pulmonary  embolism,  8th  and  37th  day        .         .         .         .     2     „ 

Amyloid  of  kidney,  20th  day 1  case 

Tetanus,  13th  and  19th  day  .         .         .         •         •        .         -2  cases 


OVARIOTOMY   BY  BILLROTH  233 

1  Of  the  first  50  cases  one  died  from  shock  and  five  from 
septicaemia. 

'  Of  the  second  50  cases  three  died  from  shock  and  two  from 
septicaemia. 

'  Of  the  last  41  cases  one  died  from  shock  and  one  from 
septicaemia. 

*  In  the  one  case  of  ileus  ovariotomy  was  done  during  the 
ileus,  and  did  not  prevent  the  death  of  the  patient. 

'  In  the  case  of  amyloid  kidney  the  operation  itself  was 
successful,  but  the  disease,  which  was  already  in  an  advanced 
stage,  made  rapid  progress  afterwards. 

'  The  pulmonary  embolism  which  occurred  on  the  37th 
day  was  not  in  any  way  connected  with  the  operation. 

'  Among  the  141  ovariotomies  nine  were  cases  of  removal 
of  both  ovaries,  and  all  recovered ;  four  patients  were  operated 
on  during  pregnancy  at  the  second,  fourth,  sixth,  and  ninth 
months,  and  all  recovered.  The  patient  operated  on  at  the 
sixth  month  aborted.     The  others  went  on  to  the  full  time.' 

Professor  Billroth,  of  Vienna,  has  very  kindly  sent  me  his 
statistics  up  to  the  end  of  October  1881,  arranged  by  himself 
in  the  following  tables. 

Table  I. 
Ovariotomies  from  1865  to  End  of  October  1881. 


Number 
222 

Died 
80 

Mortality  per  cent. 
36 

Difficulties  of  the  Operations. 

I. 

None  or  very  slight  adhesions 
of  omentum  .... 

Number 
55 

Died 
9 

Mortality  per  cent. 
16-4 

II. 

Extensive  adhesions  to  anterior 

abdominal  wall 

97 

30 

30-9 

III. 

Extensive  adhesions  deep  in  the 

pelvis,  or  with  mesentery,  in- 
testine, bladder,  uterus,  &c.  . 

65 

37 

56-9 

IV. 

Suppurating  or  putrefying  cysts 
— fever  patients    . 

Arranged  according 

5 

to  Age. 

4 

80 

1 3-20 

Number 
21 

Died 
5 

Mortality  per  cent. 
238 

21-30 

17 

303 

234 


billroth's  reports 


Table  I. — continued. 

Number 

31-40 75 

41-50 50 

51-63 20 

Arranged  in  series  of  50. 

Number 

1-50 50 

51-100 50 

101-150 50 

150-200 .50 

200-222      .        .         .        ....      22 

Treatment  of  Pedicle. 

Number 
Extra-peritoneal,  with  clamp  ...      79 
Intra-peritoneal 143 


Died 

Mortality  per  cent. 

31 

41-3 

18 

36 

9 

45 

Died 

Mortality  per  cent. 

25 

50 

17 

34 

18 

36 

16 

32 

Died 

25 

55 


18 


Mortality  per  cent. 
31-6 
38-4 


Ovariotomies  before  the  use  of  Boiled  Caroolized  Silk 
Total  number 


Number 
76 


Died 
31 


Mortality  per  cent. 
40-8 


Ovariotomies  after  the  use  of  Boiled  Caroolized  SUA. 


Total  number 
Of  those  with  spray    . 
„       without  spray 


Number  Died 

146  49 

71  29 

75  20 


Mortality  per  cent. 
33-4 
40-8 
26-6 


Table  II. 

Hospital  Cases. 

Number  Died  Mortality  per  cent. 

Total  number 140  52  37-1 

Of  those  before  the  use  of  boiled  carbolized 

silk 26  13  50 

After  the  use  of  boiled  carbolized  silk      .114  39  34-2 

In  Private  Practice  or  in  '  Maisons  de  Sante.' 

Number  Died  Mortality  per  cent. 

Total  number 82  28  34-1 

Before  the  use  of  boiled  carbolized  silk     .50  18  36 

After  the  use  of  boiled  carbolized  silk      .      32  10  31*2 

Ovariotomies,  excluding  Cases  of  Malignant  Tumours. 

Number  Died  Mortality  per  cent. 

Simple  and  multiple  cysts         ...        1  66  32*8 


REMARKS  BY   BILLROTH  235 

Table  II. — continued. 

Difficulties  of  the  Operations  as  above. 

1 53  9  16-9 

II 89  23  25-7 

III 54  29  53-7 

IV 5  4  80 

Malignant  Ovarian  Tuiwws. 

Number  Died  Mortality  per  cent- 
Total  number      21  14                 66-6 

Of  these  carcinoma 14  11                78-5 

„      sarcoma 7  3                42*8 

Billroth  has  added  the  following  important  remarks : — 
6 1  must  explain  that  only  within  the  last  three  years  have 
I  begun,  in  cases  really  too  difficult,  to  close  the  abdominal  in- 
cision and  leave  the  operation  incomplete.  Up  till  three  years 
ago  I  finished  at  any  cost  every  operation  that  I  began,  and 
this  naturally  made  the  statistics  worse.  In  the  last  three 
years  I  have  closed  the  wound  in  12  cases,  and  not  one  of  the 
patients  has  died  in  consequence  of  the  incision.  I  attach  very 
little  importance  to  figures  in  relation  to  a  method  of  operating. 
My  opinion  is  as  follows.  Granted  that  the  operation  is  well 
done,  and  that  the  patient  does  not  die  within  about  twenty- 
four  hours  from  loss  of  blood  or  shock  (which  has  occurred  to 
me  only  4  times  in  222  cases),  the  result  depends  upon  whether 
sponges,  fingers,  instruments,  secretions,  and  above  all  the 
ligature  threads,  are  clean.  If  this  be  so  all  get  well.  Three 
weeks  ago  I  operated  on  a  carcinoma  of  the  ovary  which  had 
grown  through  small  intestine  and  the  bladder.  I  cut  away  8 
centimetres  of  small  intestine,  completed  the  enteroraphie ;  then 
I  cut  away  the  upper  part  of  the  bladder  and  united  it  with  20 
sutures.  The  recovery  was  as  free  from  fever  as  in  the  simplest 
case,  and  the  patient  was  discharged  cured  after  20  days.' 

In  the  north  of  Europe,  Dr.  Skoldberg,  of  Stockholm,  de- 
serves the  credit  of  promulgating,  by  his  example  and  writings, 
the  knowledge  of  the  operation  in  Sweden.  He  published  a 
valuable  treatise  in  1867,  and  he  visited  England  again  in 
1872,  when  he  informed  me  that  he  had  performed  28  opera- 
tions, with  a  result  of  24  recoveries  and  4  deaths.  Soon  after 
his  return  to  Sweden  he  died,  but  in  the  interval  added  two 
more  successful  cases  to  his  list.     This  success  naturally  had  a 


236 


OVARIOTOMY   IN   SWEDEN 


great  influence  in  Sweden ;  and  Dr.  Howitz,  of  Copenhagen, 
and  Professor  Nicolaysen,  of  Christiania,  who  both  assisted  me 
many  times,  have  done  good  service  with  their  Danish  and 
Norwegian  countrymen.  Arendrup,  of  Copenhagen,  who  had 
highly  qualified  himself  by  assiduous  study  here  for  the  high 
position  he  appeared  destined  to  fill  in  his  native  country,  died 
too  early — a  victim  to  overwork  in  the  Paris  hospitals  during 
the  siege. 

I  have  a  return  from  Denmark  by  Dr.  Leopold  Meyer  of  41 
operations  by  Starfeldt  and  Stadfelt,  with  30  recoveries  and  11 
deaths ;  four  cases  before  antiseptics  furnished  two  of  these 
deaths.  No  information  has  been  received  from  Professor 
Howitz. 

Professor  Nicolaysen  has  sent  me  the  accompanying  tables 
which  represent  the  state  of  ovariotomy  in  Norway  up  to  the 
present  time. 


Statistics  of  the  Mortality  after  Ovariotomy  in  Norway, 
from  1864-1882. 


Place 

Total 
number  of 
operations 

Total 

number  of 

deaths 

Name  of  operator 

Remarks 

1 

56 
23 

22 
9 

Professor  Nicolaysen 
Professor  Voss 

3 

1 

Dr.  Kicer 

Kristiania          .  4 

3 

1 

Dr.  Malthe 

1 

— 

Dr.  Hald 

1 

1 

Dr.  Klem 

Bergen      .        .  j 
Molde 

1 
1 

1* 

2 

4 

1 
1 
3 

Professor  Hjort 
Professor  Nicolaysen 
Dr.  Kahrs 
Dr.  H.  Vogt 
Dr.  Hoegh 

*Not  completed 

Stavanger . 

Flekkefjord 

Porsgrund 

1* 
1* 
2 

1 
1 
1 

Dr.  Stang 

Professor  Nicolaysen 
Dr.  Munk 

*Not  completed 
*Not  completed 

Holmestrand 
Frederikshald    . 

1 
3 

1 
2 

Professor  Nicolaysen 
Dr.  Eoll 

104 

45 

Mortality  per  cent.  43-27. 


Since  the  year  1878  Professor  Nicolaysen  in  Kristiania  has 
appHed  full  Listerism  in  24  operations  (carbolic  spray  from  2  to 
4  per  cent.)  with  the  following  results : — 


DENMARK   AND    NORWAY 


237 


Treatment  of  the 
pedicle 

Total  number 
of  operations 

Number  of 
deaths 

Spencer  Wells's  clamp    . 

Ligature  

Enucleation     .... 

14 
8 
2 

2 
4 

24 

6 

Mortality  per  cent.  25-00. 

In  connection  with  them  he  makes  remarks  to  this  effect : 
That  the  great  mortality  among  the  early  cases  was  principally 
due  to  the  delay  in  seeking  relief  by  operation,  as  most  of  the 
patients  had  been  subjected  to  long-continued  medical  treat- 
ment leading  only  to  ansemia,  adhesions,  and  all  the  complica- 
tions of  old  cases.  This  has  been  in  a  measure  changed  of  late 
years,  and  the  operations  have  taken  place  at  an  earlier  stage  of 
the  disease.  At  the  same  time  antiseptic  precautions  have 
been  adopted,  the  carbolic  spray  and  dressings  being  used. 
Professor  Nicolaysen  adds  that,  '  after  having  used  sulphurous 
acid  for  cleansing  the  sponges  the  patients  have  had  no  fever 
and  all  are  recovered.'  There  is  no  special  hospital  in  Chris- 
tiania,  and  most  of  the  operations  have  been  done  in  general 
hospitals,  but  all  those  by  Professor  Nicolaysen  since  1878  were 
in  private  houses,  '  though  not  always  of  the  best  kind.' 

In  Eussia,  the  first  ovariotomy  was  performed  at  Charkoff 
by  Professor  Vanzetti  in  1846,  and  the  second  operation  at 
Helsingfors  in  1849,  by  Professor  Haartmann.  Both  cases  were 
unsuccessful.  The  first  successful  case  was  performed  by  Pro- 
fessor Krassowski,  of  St.  Petersburg,  in  December  1862,  and 
his  results  were  afterwards  so  satisfactory  that,  in  1868,  he 
published  the  well-known  atlas  of  beautifully  coloured  plates, 
with  full  accounts  of  24  cases  in  which  he  had  completed  the 
operation,  and  one  case  of  partial  extirpation.  Of  the  24 
completed  cases,  both  ovaries  were  removed  in  6 — 3  success- 
fully, and  3  followed  by  death.  Of  the  18  cases  where  one 
ovary  was  removed,  there  were  10  recoveries  and  8  deaths, 
giving  a  general  total  of  13  recoveries  and  11  deaths.  Writing 
to  me  in  1868,  Professor  Krassowski  most  kindly  assured  me 
that  my  work  had  contributed  much  to  the  progress  of  ovari- 
otomy in  Russia.  Professor  Krassowski's  example  has  been 
followed  by  many  Russian  surgeons ;  and  he  now  obliges  me 


238  OVARIOTOMY   IN  RUSSIA 

with  a  detailed  account  of  what  has  since  been  done  by  himself 
and  others.  From  this  it  appears  that  altogether  there  have 
been  302  ovariotomies  reported  by  forty  native  surgeons  in  St. 
Petersburg  and  the  various  provinces  of  Eussia.  One  hundred 
and  sixty-nine  of  these  were  successful,  leaving  133  deaths.  In 
two  of  these  cases  there  was  accidental  perforation  of  the  intes- 
tine, without  any  bad  result,  but  in  one  case  of  partial  ovariotomy 
a  sponge  was  forgotten  and  the  patient  died.  Professor  Kras- 
sowski  himself  has  operated  on  124  patients,  completing  the  re- 
moval in  112  cases,  with  63  recoveries  and  49  deaths,  and  being 
obliged  to  leave  it  partially  done  in  12  instances  with  a  loss  of 
7  patients.  One  of  his  operations  for  ovariotomy  was  compli- 
cated with  pregnancy ;  twice  he  met  with  small  fibroids  of  the 
ovaries,  and  twice  also  he  had  to  take  away  a  considerable  por- 
tion of  the  omentum.  No  account  is  published  of  many  of  the 
ovariotomies  done  in  Eussia,  and  Professor  Krassowski  is  per- 
suaded that  the  number  is  much  greater  than  he  has  been  able 
to  collect.  All  but  one  of  the  ovarian  cases  which  have  come 
to  me  from  Eussia  recovered  from  the  operation.  One  only 
died  afterwards  from  obstruction  of  the  intestine.  The  others 
have  had  no  return  of  the  disease.  I  shall  have  to  allude  here- 
after to  the  important  observations  of  Dr.  Maslowsky  upon  the 
pathological  phenomena  which  follow  the  application  of  liga- 
tures and  of  the  cautery  to  a  pedicle. 

In  Italy  the  first  successful  ovariotomy  was  performed  by 
Professor  Landi,  of  Pisa,  in  September  1868 ;  the  second,  by 
Professor  Peruzzi,  of  Lugo,  in  1869  ;  the  third,  by  Dr.  Mar- 
zolo,  of  Padua,  in  July  1871.  In  his  account  of  this  operation, 
Dr.  Marzolo  says  that  it  is  the  sixteenth  ovariotomy  performed 
in  Italy,  the  results  having  been  3  recoveries  and  13  deaths; 
and  he  joins  with  Landi  in  urging  his  countrymen,  by  courage 
and  perseverance,  to  emulate  the  successes  of  their  English 
brethren. 

This  they  certainly  have  done  even  with  rapidly  improving 
results.  In  the  first  hundred  cases  performed  in  Italy  Peruzzi 
proved  that  the  recoveries  were  37  and  the  deaths  63,  while  in 
the  second  hundred  these  figures  were  rather  more  than  re- 
versed, the  recoveries  being  64  and  the  deaths  only  36,  a  per- 
centage which  doubtless  will  be  smaller  in  the  third  hundred. 

The   following   paper,  which  was  printed  in  the  '  British 


OVARIOTOMY  IN  ITALY  239 

Medical  Journal,'  November  23,  1878,  is  interesting  in  connec- 
tion with  the  history  of  ovariotomy  in  Italy. 

'In  the  "British  Medical  Journal"  of  March  16,  1878,  I 
published  a  short  account  of  a  case  sent  to  me  by  my  friend  Dr. 
Peruzzi,  of  Lugo,  and  I  arrived  at  the  conclusion  which  I  ex- 
pressed in  these  words  :  "  It  is  very  desirable  that  the  specimen 
should  be  carefully  examined.  If  it  be  really  an  ovary,  it  will 
certainly  appear  that  the  first  case  of  ovariotomy  in  Europe  was 
that  by  Emiliani,  of  Faenza,  in  1815.  I  have  written  to  Dr. 
Peruzzi,  suggesting  that  the  specimen  should  be  examined  by 
some  competent  morbid  anatomist." 

4  Dr.  Peruzzi  cordially  acted  upon  my  suggestion,  and  I  had 
the  pleasure  of  meeting  him  in  Paris  last  September,  and  I  ex- 
amined the  specimen  with  him  and  Dr.  Marion  Sims,  in  the 
laboratory  of  Professor  Ranvier,  with  whom  the  specimen  was 
left  for  a  more  prolonged  examination.  Dr.  Peruzzi  has  lately 
sent  me  Professor  Eanvier's  report,  of  which  the  following  is  a 
literal  translation : — 

' "  A  tumour,  after  long  preservation  in  alcohol,  has  been 
submitted  to  me  by  Dr.  Peruzzi  for  histological  examination. 
This  tumour  was  brought  from  the  museum  of  the  Medico- 
Chirurgical  Society  of  Bologna.  The  surgeon  who  extirpated  it 
— Dr.  Emiliani,  of  Faenza,  in  1815 — thought  it  had  been  formed 
"by  the  ovary,  but  nothing  can  be  distinguished  which  resem- 
bles the  Graafian  follicles;  it  is  nearly  homogeneous  (aasez 
homogene).  Microscopical  sections,  made  in  different  parts  of 
the  morbid  mass,  were  first  placed  in  water ;  then  they  were 
submitted  to  the  action  of  picrocarminate  of  ammonia ;  lastly, 
they  were  put  up  as  preparations  in  glycerine.  Owing  to  the 
prolonged  action  of  alcohol  (sixty-three  years)  on  the  speci- 
men, coloration  by  the  picrocarminate  is  feeble,  but  it  is  suffi- 
cient to  render  the  elements  distinguishable.  In  all  the  sections 
which  have  been  made,  we  only  observe  fibrous  tissue  and 
blood-vessels.  The  fibrous  tissue  is  characterised  by  the  con- 
nective fasciculi,  interlaced  in  different  directions,  and  by  con- 
nective cells.  The  arteries  are  recognised  by  their  muscular 
coat,  which  is  well  preserved.  The  veins  and  capillaries  are 
dilated  and  filled  with  blood  ;  the  white  and  red  corpuscles  are 
still  recognisable,  which  proves  that  the  preservation  of  the 
tumour  is  relatively  good. 


240 


OVARIOTOMY   IN   ITALY 


'  "  In  none  of  the  preparations  that  I  have  made  are  there 
any  glandular  channels,  cysts,  or  Graafian  follicles.  Still  it 
might  be  possible  that  the  morbid  tissue  had  originated  (pris 
oiaissance)  in  the  ovary;  but  then  it  would  be  necessary 
to  admit — which  is  not  improbable — that  it  has  caused  the 
complete  disappearance  of  the  characteristic  elements  of  that 
organ. 

"  L.  Kanvier. 

"  Paris,  September  22,  1878." 
*  The  exact  size  and  form  of  this  tumour  are  well  represented 


in  the  annexed  woodcut.  The  length  is  9  centimetres  (3^ 
inches) ;  greatest  breadth,  5  centimetres  (2  inches) ;  circum- 
ference, 15^  centimetres  (6  inches). 

*  Dr.  Peruzzi  wrote  to  me  that  he  does  not  consider  this 
report  affects  the  question  of  priority  in  favour  of  Italy  having 
the  first  claim  to  the  performance  of  ovariotomy  in  Europe. 


OVARIOTOMY    IN   THE   COLONIES  241 

Nor  does  he  think  the  clinical  history  contradictory.  The 
tumour  was  found  the  day  after  the  injury,  and  it  is  impossible 
that  it  could  have  formed  in  that  short  time.  It  must,  there- 
fore, have  existed  before,  and  contributed  to,  the  peritonitis 
which  followed  the  injury ;  and  we  know  how  often  ovarian 
tumours  are  accidentally  discovered. 

'  All  this  is  incontestable.  But  I  do  not  think  this  case  can 
be  regarded  as  a  case  of  ovariotomy  in  the  sense  in  which  this 
operation  has  been  regarded,  from  its  first  performance  by 
McDowell  to  the  present  time.  Until  Battey's  recent  proposal 
to  remove  "  normal "  ovaries,  or  ovaries  only  slightly  enlarged, 
no  ovariotomist  ever  contemplated  the  removal  of  an  ovary  not 
measuring  more  than  three  inches  by  two  inches.  The  re- 
moval of  such  a  tumour  could  have  no  more  bearing  upon  the 
rise  of  ovariotomy  than  the  removal  of  a  hernial  ovary  from 
the  inguinal  canal.  Emiliani,  no  doubt,  believed  he  had 
removed  a  "  scirrhous  ovary,"  and  it  is  certain  that  he  removed 
a  fibrous  tumour  which  may  or  may  not  have  originated  in  the 
ovary.  Professor  Eanvier  wrote  with  extreme  caution ;  but  I 
gather  from  his  report  that,  as  the  specimen  was  sufficiently 
well  preserved  for  arteries,  veins,  capillaries,  and  both  red  and 
white  blood-corpuscles  to  be  still  recognisable,  it  is,  to  say  the 
least,  very  remarkable  (presuming  the  growth  to  be  ovarian) 
that  no  Graafian  follicles  or  any  characteristic  ovarian  structure 
is  preserved.' 

It  is  not  easy  to  obtain  information  as  to  the  number  and 
result  of  cases  of  ovariotomy  in  Spain  and  Portugal,  but  there 
is  reason  to  believe  that  they  do  not  differ  greatly  from  those 
of  Italy. 

In  India,  as  early  as  1860,  ovariotomy  was  performed  suc- 
cessfully at  Tanjore,  by  a  native  surgeon.  The  particulars  are 
given  in  the  '  Medical  Times  and  Gazette  '  of  1861.  In  Aus- 
tralia, the  success  of  Tracy  and  of  Martin  has  been  equal  to 
that  of  their  English  brethren.  In  New  Zealand,  Dr.  Mackin- 
non  was  the  pioneer  of  ovariotomy  at  our  antipodes.  In 
Canada,  the  few  cases  which  have  been  published  have  been 
almost  all  successful ;  and  there  is  already  abundant  evidence 
that  ovariotomy  may  be  practised  successfully  under  the  most 
different  conditions,  and  in  the  most  opposite  climates. 

1  know  of  one  ease  reported  from  Japan  in  1880. 

B 


242  OVARIOTOMY    IN   AMERICA 

It  is  impossible  to  give  anything  like  a  full  historical 
sketch  of  the  progress  of  ovariotomy  in  America  within  any 
reasonable  limits.  The  initiatory  work  of  McDowell  has  been 
already  described.  Atlee  stands  next  to  myself  in  the  number 
of  operations  he  performed.  Kimball,  of  Lowell,  Peaslee, 
Marion  Sims,  Storer,  and  many  other  American  surgeons 
have  maintained  the  reputation  of  their  country  in  this 
department  of  surgery.  Works  by  Atlee  and  Peaslee  were 
published  in  1872,  and  their  European  brethren  have  read 
with  great  interest  their  account  of  their  own  work  and  that 
of  their  countrymen. 

The  recent  treatises  of  Thomas  and  Emmet  give  no  sufficient 
details  to  represent  the  actual  number  of  ovariotomies  in 
America,  but  the  known  skill  and  perseverance  of  the  surgeons 
of  that  continent  fully  justify  us  in  supposing  that  they  are 
in  no  respect  behind  their  European  fellow- workers.  In  the 
work  just  issued  by  Agnew,  Professor  of  Surgery,  Pennsylvania, 
there  is  a  table  compiled  by  Baum  of  5,153  cases  of  ovariotomy, 
of  which  3,651  recovered  and  1,502  died  =  29*13  mortality  per 
cent.     Of  these  there  were — 


Recovered 

Died 

Single      .        .         .       4,969 

3,531 

1,438 

= 

28-94 

Double     ...           183 

120 

63 

= 

34-42 

During  pregnancy  .            21 

17 

4 

= 

19-05 

Twice  on  same  patient        15 

12 

3 

= 

20-00 

But    this    table    includes   cases   both   of  American   and 
European  surgeons. 


OVARIAN    DISEASE  243 


CHAPTER   VI. 

OVARIAN   DISEASE   IN   ENGLAND,  AND    THE    CONDITIONS    AFFECTING 
THE    OPERATION    OF    OVARIOTOMY. 

The  last  report  of  the  Registrar-Gfeneral,  the  forty-second,  is 
dated  1881,  and  gives  the  returns  for  1879. 

In  that  year  the  estimated  population  of  England  and 
Wales  was  25,165,336;  the  number  of  females  12,917,057, 
which  we  may  practically  regard  as  13,000,000.  The  number 
of  deaths  from  all  causes  in  the  whole  population  was  526,255  ; 
among  females  only,  254,759. 

The  number  of  deaths  entered  as  caused  by  ovarian  or 
encysted  dropsy  has  varied  considerably  in  successive  years. 
During  the  five  years  1876-80  it  rose  for  three  years,  attaining 
the  highest  point  in  the  third  year,  then  again  declined,  and  in 
1880  once  more  went  up.  The  registration  stands  thus  :  for 
1876,  327  deaths  from  ovarian  dropsy,  73  after  ovariotomy; 
for  1877,  355  disease,  96  operation;  for  1878,367  disease, 
99  operation;  for  1879,  255  disease,  88  operation;  and  for 
1880,  298  disease,  86  operation.  The  report  for  1880  is  not 
yet  on  sale  to  the  public,  but  Dr.  Ogle  has  obligingly  furnished 
me  with  the  numbers. 

Dr.  Farr,  in  his  letter  to  the  Registrar-Greneral  on  the  causes 
of  death  in  1878,  as  published  in  the  forty-first  annual  report, 
says  that  the  mortality  from  ovarian  dropsy  had  increased  to 
the  number  of  that  year,  from  196  in  1851,  so  that  in  fact  it 
had  more  than  doubled  in  twenty-eight  years,  notwithstanding 
the  many  lives  saved  by  ovariotomy.  There  have,  however, 
been  such  irregular  fluctuations  in  the  number  of  deaths,  that 
comparison  of  one  year  only  with  any  other  single  year  is  falla- 
cious ;  and  for  the  same  reason,  that  any  calculations  based 
upon  the  returns  of  one  year  only  would  be  misleading,  I 
prefer   taking  the    average    of  the    registration    numbers   for 

B   2 


244  OVARIAN    DISEASE 

the  last  five  years  which  are  available,  that  is,  from  1876-80 
inclusive,  as  the  starting-point  of  my  investigation  of 
some  of  the  problems  of  the  statistics  of  ovariotomy.  This 
average  is  a  total  of  320  deaths  from  disease  and  88  after 
ovariotomy. 

The  mean  annual  rate  of  mortality  in  England  and  Wales 
for  25  years,  1850  to  1874,  from  encysted  dropsy  was  11*1  per 
million  of  the  whole  population  ;  in  the  years  1875  and  1876  it 
was  14;  in  the  years  1877  and  1878  it  was  15  ;  in  1879  it  was 
again  14  ;  and  per  million  of  females  27. 

The  estimated  population,  in  round  numbers,  of  25,000,000 
in  1879,  or  for  the  five  years  in  question,  would,  at  the  annual 
rate  of  mortality  of  14  per  million  of  the  whole,  or,  as  given  in 
the  last  official  report,  27  per  million  of  females,  furnish  324 
deaths  from  ovarian  dropsy,  which  is  within  four  of  the  average  of 
registration  for  our  five  years.  But  over  and  above  these  320 
deaths  from  disease  is  a  mortality  of  88  after  ovariotomy,  which, 
at  the  old  rate  of  25  per  cent,  loss  by  operation,  implies  the 
performance  of  352  operations,  and  the  existence  of  264  women 
recovered  from  the  operation,  who,  without  it,  would  in  all 
probability  have  died  within  the  year,  and  raised  the  total 
number  of  deaths  from  ovarian  dropsy  to  672. 

Of  the  12,917,057  females  in  England  and  Wales,  one  of 
every  19,221  comes  annually  under  treatment,  medical  or 
surgical,  for  ovarian  dropsy,  and  is  either  cured  or  reported  as 
dead. 

One  of  every  31,659  dies  either  of  the  disease  or  after 
ovariotomy,  between  one-fourth  and  one-fifth  of  the  deaths 
following  the  operation. 

Calculations  based  upon  the  Kegistrar's  report  make  it  appear 
that  the  female  population  of  England  and  Wales  comprises  an 
average  of  about  11,000  cases  of  ovarian  disease,  with  an  esti- 
mated duration  of  life  of  four  years  each ;  and  with  each  suc- 
ceeding year  an  increase  of  distress  and  incapacity  for  taking 
part  in  the  duties  and  pleasures  of  life. 

From  what  has  been  stated  above  it  seems  that  only  a 
sixteenth  part,  or  6*1  per  cent,  of  the  11,000  diseased  women, 
are  annually  registered  as  dead,  or  known  to  be  operated  on, 
that  is,  come  under  medical  or  surgical  supervision ;  the  dead 
tell  up  to  3*7  per  cent.,  the  ovariotomized  to  3*2  per  cent. ; 


STATISTICS    OF   MORTALITY    IN    ENGLAND  245 

2*4  per  cent,  of  which  number  are  cured  by  the  operation  and 
08  per  cent.  die.  The  remaining  10,328  invalids  must  be 
either  submitting  passively  to  the  progress  of  their  malady,  or 
contenting  themselves  with  palliative  measures,  with  the  excep- 
tion of  the  few  single  cyst  cases  curable  by  tapping,  which, 
even  if  we  take  the  figures  of  Boinet,  may  be  set  down  in 
fractions. 

Speaking  of  the  last  ten  years,  one  may  say  that  formerly  of 
those  operated  on  75  per  cent,  were  saved  from  their  disease 
and  25  per  cent,  died ;  but  at  the  present  time  things  are  so 
much  altered  that  the  mortality  after  ovariotomy  is  reduced  to 
4,  10,  12,  or  15  per  cent.,  according  to  circumstances  and  the 
operator,  and  the  risk  of  the  operation  is  somewhat  less  than  4 
per  cent,  above  that  of  the  disease  itself.  Or,  to  put  the  same 
thing  in  other  words,  if  100  women,  having  the  disease  of  which 
most  of  them  would  die  within  the  year,  and  all  within  four 
years  of  misery,  were  to  submit  to  the  operation  of  ovariotomy, 
the  chances  are  that  10  or  15  would  die  after  it,  but  85  or  90 
would  regain  life  and  the  probability  of  enjoying  it  for  nearly, 
and  in  many  instances  the  whole  of,  the  natural  term. 

The  following  memoranda  as  to  the  statistics  of  mortality 
from  ovarian  dropsy  with  which  I  have  recently  been  favoured 
by  Dr.  Ogle  will  be  read  with  interest. 

*  In  the  earlier  years  of  civil  registration  the  number  of 
deaths  ascribed  to  ovarian  dropsy  was  extremely  small,  doubt- 
less owing  to  imperfect  diagnosis,  many  deaths  which  were  really 
due  to  it  being  vaguely  described  as  caused  by  '  dropsy  '  or  '  ab- 
dominal tumour.'  In  the  five  years  1838-42  only  218  deaths 
from  ovarian  dropsy  were  registered,  or  an  average  of  44  a  year. 

'  After  this  there  is  a  gap  in  the  reports  of  the  Registrar- 
General,  the  causes  of  death  not  having  been  abstracted  for  a 
period  of  four  years  (1843-46).  In  this  interval  the  attention 
generally  of  medical  men  was  directed  to  the  disease,  this 
being  the  time  when  Dr.  Clay's  long  series  of  operations  began, 
and  when,  moreover,  the  first  successful  operation  in  London 
was  performed. 

'  Consequently,  when  the  Registrar-General  again  began  to 
abstract  the  causes  of  death,  in  1847,  we  find  that  the  number 
of  deaths  ascribed  to  ovarian  disease  had  suddenly  jumped  up 
from   the  previous  average  of  44  to  193.     The  average  annual 


246 


STATISTICS   OF   MORTALITY   IN   ENGLAND 


mortality  ascribed  to  this  cause  has  since  that  date  been  as 
follows : — 


Peiuod 

Average  annual  mortality 
from  ovarian  dropsy 

1847-50 
1851-55 
1856-60 
1861-65 
1866-70 
1871-75 
1876-80 

207 
204 
242 
248 
229 
222 
320 

These  figures  are  exclusive  of  deaths  ascribed  to  ovariotomy. 

*  Limiting  ourselves  to  the  decennial  period  just  completed 
(1871-80),  as  being  that  in  which  the  disease  has  been  most 
completely  recognized,  and  in  which  registration  has  been  most 
accurate,  we  have  an  average  of  271  deaths  ascribed  annu- 
ally to  ovarian  dropsy,  to  which,  however,  must  be  added  an 
average  of  70  more  ascribed  to  ovariotomy. 

'  The  maxima,  both  for  ovarian  dropsy  and  for  ovariotomy, 
were  in  the  years  1877  and  1878,  when  the  deaths  from  the 
two  causes  combined  numbered  451  and  466  respectively.  In 
the  two  following  years,  1879  and  1880,  there  was  a  notable 
decline  in  the  registered  mortality,  the  deaths  from  the  two 
causes  numbering  only  343  in  the  former  year  and  384  in  the 
latter. 

'  This  decline  in  mortality  was  so  sudden  and  so  great — 
more  than  26  per  cent. — that  it  would  appear  impossible  to 
attribute  it  entirely  to  the  improved  treatment  of  the  disease 
and  the  improved  methods  of  operation.  Moreover,  it  is  to  be 
noticed  that  an  equally  sudden  and  still  greater  change  in  the 
mortality,  but  in  a  contrary  direction,  occurred  in  1875,  when 
the  mortality  suddenly  rose  by  no  less  than  85  per  cent.' 

All  these  details  have  a  special  professional  interest.  They 
open  up  to  us  a  view  of  the  field  of  labour  which  lies  before  us. 
They  give  us  an  impression  of  the  weight  of  responsibility  in 
the  way  of  preparation  for  so  great  a  task.  They  enable  us  to 
estimate  our  powers  and  resources  for  attempting  it.  And 
while  they  throw  a  shadow  of  regret  upon  the  deficiencies  of 
the  past,  they  certainly  do  not  fail  to  afford  us  encouragement, 
and  to  make  us  hope  that  our  art  may  henceforth  prove  effec- 


THE    QUESTION   OF    OPERATIVE    TREATMENT  247 

tual  in  lightening  the  amount  of  female  suffering  and  rescuing 
a  vast  proportion  of  threatened  life. 

But  there  is  a  great  distinction  between  general  statistics, 
showing  what  can  be  done  for  the  disease  as  a  whole,  how  it 
can  be  dealt  with  as  a  nosological  item,  and  the  question  so 
all  important  to  a  sick  woman,  what  can  be  done  for  her  parti- 
cular case.     She   does  not  know,  nor  does  she  want  to  know, 
anything  about  ratios.     Her  interest  centres  in  herself,  and  her 
inquiries  naturally  confine  themselves  to  what  prospect  we  can 
offer  of  cure,  and  whether  there  is  a  chance  that  we  can  relieve 
her  without  putting  her  life  in  too  great  risk.     Or  it  may  come 
to  this,  that  her  sufferings  are  too  great  for  her  to  regard  the 
danger,  and  she  only  looks  at  the  glimpse  of  hope  which  the 
something  to  be  done  gives  her,  first  of  relief  from  her  burden, 
and,  as  a  secondary  consideration,  of  the  prolongation  of  her 
life  when  freed  from  it. 

The  cases  which  come  under  the  hands  of  the  surgeon   fall 
naturally  into  two  groups ;  those  in  which  the  condition  admits 
of  temporary  relief,  or  in  which  circumstances  make  it  all  that 
is  practicable,  and  those  in  which  the  urgency  is  such  as  to 
demand  life-saving  measures.     I  have  already  dealt  with  the 
former  series,  and  pointed  out  what  are  the  palliative  measures 
that  may  be  resorted  to  and  the  limits  within  which  they  can 
be    employed   with    safety.     I   now   proceed   to   treat  of  the 
conditions  which  indicate  the   propriety  of  operative  surgical 
interference,  and  the  considerations   which    should  guide  the 
surgeon  in  giving  his  advice,  and  must  be  presented  to  the 
patient  and  her  friends  to  aid  them  to  come  to  a  decision  to 
accept  or  reject  it.     But  of  the  patients,  whose  symptoms  call 
for  immediate  action,  and  whose   distress  is   equally  apparent, 
some  ought  to  be  given  the  chance  of  a  preliminary  tapping, 
while  others  must  without  hesitation  be  advised  to  submit  to 
the  more  severe  ordeal  of  ovariotomy. 

A  woman  with  a  single  unilocular  cyst  will  often  suffer  to 
such  a  degree  from  rapid  accumulation  and  distension  that  she 
must  be  saved  by  some  means  from  the  effect  of  mechanical 
pressure.  Once  assured  that  the  cyst  really  is  simple,ta  pping 
is  fco  be  tried;  and  in  fact  it  should  be  enforced  by  almost  a 
refusal  to  do  ovariotomy  until  it  had  been  tested.  But  this 
advice  as  to  tapping,  and  especially  as  to  renewed  tapping,  as  a 


48  THE   QUESTION   OF   OPERATIVE   TREATMENT 

means  of  cure  must  be  restricted  absolutely,  as  I  have  before 
stated,  to  simple  cases  in  which  the  cyst  is  single  and  the  con- 
tents clear  and  non-albuminous.  The  cases  in  which  all  mere 
palliative  considerations  are  to  be  put  aside  are  those  which  come 
with  the  tumour  developed  in  a  multilocular  or  dermoid  form, 
and  suffer  from  the  local  and  constitutional  effects.  A  woman 
thus  diseased  will  be  enormously  swollen  and  tormented  more 
than  in  pregnancy  by  the  distension  of  the  resisting  abdominal 
walls  ;  her  physiognomy  will  betray  the  mental  anguish  and 
the  ravages  of  disease  ;  her  respiration  will  be  embarrassed  and 
the  heart's  action  impeded  ;  nutrition  will  be  imperfect,  as  shown 
in  her  wasting ;  all  the  ordinary  functions  will  be  more  or  less 
suspended ;  she  will  be  suffering  a  variety  of  pains  direct  and 
sympathetic,  and  the  aggregate  of  her  miseries  will  be  almost 
insupportable.  All  this  will  be  manifest  in  the  enfeeblement 
of  her  mental  powers,  in  her  sleeplessness  and  restlessness,  in 
her  inability  to  go  upstairs  without  breathlessness,  to  walk  more 
than  half  a  mile  without  exhaustion,  in  her  want  of  appetite  or 
impaired  digestion,  in  the  irregularities  of  the  action  of  the 
intestines,  kidneys,  and  other  organs,  in  the  daily  increasing 
difficulty  of  fulfilling  her  domestic  duties,  and,  among  the  poor, 
by  the  reluctant  giving  up  of  her  means  of  living.  Here  there 
must  be  no  faltering,  no  suggestion  of  alternatives  or  delay. 
Justice  to  the  patient  demands  a  most  positive  recommendation 
of  excision,  and  a  clear  explanation  of  the  motives  which 
should  influence  assent  in  all  cases  where  the  contra-indi- 
cations  which  I  shall  afterwards  mention  do  not  exist.  And 
generally,  when  no  secondary  circumstances  intervene,  the 
advice  for  the  operation  should  be  accompanied  by  a  warning 
against  the  danger  of  delay.  It  is  not  often  desirable  to  detail 
to  a  patient  or  the  friends  all  the  grounds  upon  which 
this  advice  is  founded ;  but  every  one  who  takes  upon  himself 
the  responsibility  of  such  counsel  should  have  a  clear  idea  of 
the  whole  of  the  base  upon  which  it  rests.  And  it  may  be 
traced  out  summarily  in  this  form.  The  general  health  has 
already  deteriorated,  and  though  the  tumour  itself  be  not 
malignant,  and  it  may  contain  nothing  more  than  normal 
tissues  and  fluid  so  hermetically  encased  that  it  has  no  imme- 
diate influence,  as  is  proved  by  the  long  detention  of  purulent 
matter  without  secondary  symptoms,  yet  its  mere  presence  is 


REASONS  FOR  NOT  DELAYING  AN  OPERATION      249 

manifestly  the  cause  of  the  patient's  decline.  To  let  things 
go  from  bad  to  worse  without  doing  anything,  especially  when 
that  worse  is  a  certainty,  would  be  acting  against  the  very  first 
principles  of  medical  science.  And  that  the  worse  must  come, 
and  quickly  too,  in  all  but  a  few  exceptional  instances,  is  only 
too  well  known  to  everybody.  Then  the  unnatural  presence 
of  this  morbid  growth  in  the  body,,  where  it  takes  up  the 
space  belonging  to  other  organs  and  may  propagate  its  own  evil 
influence,  gives  rise  to  other  diseases.  It  attaches  itself  often- 
times to  the  intestines  which  are  in  contact  with  it,  mechani- 
cally blocks  the  passage  through  them,  or  causes  fatal  contrac- 
tions, and,  at  the  very  least,  impairs  their  functions  and  hinders 
the  due  assimilation  of  food  and  nourishment  of  the  body.  As 
for  the  bad  effects  which  it  produces  on  the  action  of  the 
thoracic  organs,  it  needs  only  that  I  refer  to  a  valuable  paper 
read  by  Dr.  Day  before  the  Eoyal  Medico-Chirurgical  Society  in 
April  1875.  He  therein  points  out  the  many  dangers  which 
threaten  life  and  render  more  riskful  the  operation  by  allowing 
time  for  the  balance  of  the  action  of  the  heart  and  lungs  to 
be  deranged,  and  for  structural  changes  to  take  place,  which, 
if  not  immediately  fatal  or  sufficient  to  mar  the  operation, 
embitter  after-days  and  render  almost  nugatory  what  has  been 
done. 

As  time  advances,  the  natural  tendency  of  the  tumour  to 
degenerative  changes  finds  scope  for  progress.  Whatever  its 
tissues  may  be,  they  are  never  lastingly  normal,  have  a  precari- 
ous parasitic  existence,  gain  their  supply  of  blood  as  it  were 
surreptitiously,  and  are  easily  thrown  into  the  condition  of 
atrophic  decay.  The  expansion  of  the  membranous  com- 
partments obliterates  the  vessels,  fatty  and  other  changes 
occur,  and  rupture  is  always  imminent.  The  contents  too, 
whatever  they  may  have  been  at  first,  alter  in  their  character 
and  become  less  and  less  benign.  And  it  would  be  contrary 
to  analogy  to  say  that  by  too  long  waiting  sympathetic  morbid 
action  may  not  be  set  up  in  the  corresponding  organ,  and 
thus  make  the  ablation  of  both  instead  of  a  single  operation 
imperative. 

Time,  too,  gives  the  opportunity  for  adhesions  to  form,  and 
though  I  do  not  regard  the  ordinary  amount  of  them  as  much 
influencing  the  success  of  ovariotomy,  there  is  no  guarantee 


250  REASONS   FOR   NOT   DELAYING   AN    OPERATION 

that  they  may  not  elect  the  pelvis  as  their  seat  and  become 
insuperable.  And  accidents  may  befall  a  woman  in  this  condi- 
tion of  suspense.  There  is  no  available  assurance  against  them, 
and  they  may  induce  rupture  or  destructive  peritonitis.  With 
some  tumours  growing  on  a  loug  pedicle  twisting  may  occur, 
with  all  the  concurrent  probabilities  of  haemorrhage  and  ex- 
haustion. I  have  but  little  to  say  about  the  contingency  of 
conception  and  pregnancy,  because  it  is  an  avoidable  compli- 
cation. Still  it  is  no  less  to  be  thought  of  and  made  the  subject 
of  warning.  Finally,  if  an  operation  has  been  proposed  and 
accepted  by  the  patient  and  those  interested  in  her,  it  must  be 
taken  for  granted  that  none  of  the  contra-indications  hereafter 
to  be  noticed  are  present,  and  that  everything  being  then  and 
there  reasonably  favourable  for  success  has  formed  part  of  the 
argument  authorizing  an  operation.  Who  can  promise  a  more 
auspicious  moment  in  the  future  ?  This  is  not  the  province 
of  the  surgeon.  His  responsibility  ends  with  his  advice  as  to 
fact  and  time,  and  in  the  interval  between  his  advice  and 
action  it  is  for  the  patient  to  decide  whether  or  not  and  when 
her  life  is  to  be  hazarded. 

In  many  cases  ovariotomy  maybe  performed  with  a  confident 
hope  of  a  successful  result  ',  in  others  the  probabilities  of 
success  or  failure  may  be  about  equal,  while  in  some  the 
hope  of  success  is  so  small,  that  most  patients,  who  are  told 
the  whole  truth,  prefer  waiting  for  the  natural  termination 
of  the  disease  to  voluntarily  placing  their  lives  in  immediate 
peril.  Some,  however,  would  urge  the  unwilling  surgeon  to 
operate  against  his  better  judgment,  and  I  have  often  yielded 
to  the  solicitations  of  patients  who,  their  sufferings  being 
great  and  death  being  inevitable  at  no  distant  period,  have 
preferred  running  any  risk  rather  than  submit  to  a  continua- 
tion of  suffering  to  be  ended  by  certain  death.  In  only 
one  case  have  I  refused  to  operate  when  pressed  to  do  so  by 
a  patient  capable  of  appreciating  the  difficulties  of  the  position. 
In  this  case,  a  woman  in  the  Samaritan  Hospital  suffered,  as  I 
believed,  from  malignant  disease,  involving  the  uterus  and 
both  ovaries,  and  having  a  large  quantity  of  fluid  free  in  the 
peritoneal  cavity ;  I  removed  this  fluid,  but  refused  to  do  more, 
although  the  woman  threatened  to  commit  suicide  if  1  did  not 
operate      After  her  death,  the  correctness  of  the  diagnosis  was 


CONDITIONS   AFFECTING   OVARIOTOMY  251 

fully  borne  out.  I  have  heard  of  some  few  cases  where  patients 
whom  I  had  dissuaded  from  the  operation  have  been  en- 
couraged by  others  to  submit  to  it,  and,  with  one  exception, 
every  such  patient  has  died  after  the  operation.  The  exceptional 
case  was  a  woman  who  had  been  several  times  tapped,  and  who 
had  been  advised  both  by  Dr.  Keith  and  by  me  not  to  think  of 
ovariotomy  so  long  as  life  could  be  made  tolerable  by  tappings. 
Fifteen  months  after  I  saw  her  the  tumour  was  removed  by 
Dr.  Graham,  of  Liverpool,  who  encountered  and  overcame  the 
pelvic  and  other  adhesions  which  Dr.  Keith  and  I  both  recog- 
nized, and  obtained  the  satisfaction  of  saving  a  life  otherwise 
inevitably  lost.  I  have  thought  it  necessary  to  make  this 
statement  distinctly,  because  it  has  been  supposed  that  ovari- 
otomy has  been  restricted  to  favourable  cases  only,  and  that 
good  results  had  been  obtained  by  refusing  to  operate  upon 
any  but  selected  cases.  Indeed,  this  was  the  case  in  the  .early 
days  of  ovariotomy  in  this  country.  Dr  Frederick  Bird,  for 
instance,  published  numerous  cases  where,  after  making  a 
small  incision,  and  finding  the  cyst  adherent,  he  did  not 
proceed  with  the  operation ;  and  Dr.  Clay,  of  Manchester,  does 
not  appear  to  have  performed  ovariotomy  upon  more  than 
an  eighth  of  the  patients  with  ovarian  tumours  who  consulted 
him. 

Before  going  into  the  numerical  examination  of  the  question 
as  to  how  far  the  age  and  condition  of  the  patient,  the  size  of 
the  tumour,  the  existence  of  adhesions,  the  length  of  the  pedicle, 
and  any  other  jmrticulars  which  can  be  ascertained  or  made  out 
with  tolerable  accuracy  when  the  question  of  operation  is  dis- 
cussed, have  affected  the  result  in  the  1,000  cases  upon  which  this 
volume  is  founded,  I  think  we  may  conclude  that  this  expe- 
rience has  now  been  sufficient  to  warrant  the  acceptance  of  some 
such  rule  as  the  following : — 

The  probable  result  of  ovariotomy  can  be  estimated  with 
far  greater  accuracy  by  a  knowledge  of  the  general  condition  of 
the  patient,  than  by  the  size  and  condition  of  the  tumour. 

In  other  words,  a  large  tumour,  extensively  adherent,  in  a 
patient  whose  heart  and  lungs,  and  digestive  and  eliminative 
organs,  are  healthy,  and  whose  mind  is  well  regulated,  may  be 
removed  with  a  far  greater  probability  of  success  than  a  small 
una  I  tucked  cysl    from   a   patient  who  is  una?mic  or  leukemic, 


252  CONDITIONS   AFFECTING    OVARIOTOMY 

whose  heart  is  feeble,  whose  assimilation  and  elimination  are 
imperfect,  or  whose  mind  is  too  readily  acted  upon  by  either 
exciting  or  depressing  causes.  I  believe  this  to  be  the  expla- 
nation of  the  facts  which  have  led  some  superficial  observers 
to  assert  that  the  more  advanced  the  disease  the  greater,  and 
the  earlier  the  stage  of  the  disease  the  less,  is  the  probability  of 
recovery.  I  am  convinced  that  this  reasoning  is  based  on  the 
observation  of  a  few  exceptional  cases  where  small  unattached 
tumours  have  been  removed  with  a  fatal  result  from  unhealthy 
persons  ;  or  where  large  attached  tumours  have  been  success- 
fully removed  from  persons  who  have  otherwise  been  con- 
stitutionally sound ;  but  small  unattached  tumours  in  strong 
healthy  persons  by  no  means  give  the  best  results.  It  is 
possible  to  operate  too  early  as  well  as  too  late — to  place  a 
patient's  life  in  peril   by  operation   before   it   is   endangered 

/  by  the  disease  ;xju"st  as  it  is  possible,  on  the  other  hand,  to 
delay  operation  until  the  powers  of\life  are  so  exhausted  that 
recovery  after  a  severe  ^operation  islimpossible.     In  the  same 

Nway,  a  strong  man  in  full  health,  with  a  limb  crushed  by  a 
railway  accident  or  shattered  by  a  j  bullet,  bears  amputation 
worse  than  another  mam  who,  on  account  of  diseased  knee-joint, 
has  been  confined  to  am  room  for  w#eks  or  months ;  or  a  woman 
who  has  become  accustomed  to  the/ confinement  of  a  sick  room, 
has  lost  flesh,  an~d-4ms  been  br-ought  by  her  suffering  to  dread 
the  operation  less  manttie  disease,  bears  the  removal  of  an 
ovarian  tumour,  even  though  large  and  adherent,  better  than 
one  whose  whole  course  of  life  is  suddenly  changed  from  the 
performance  of  ordinary  active  duties  to  the  enforced  quiet 
and  confinement  in  bed  which  necessarily  follow  ovariotomy. 


SIZE. 

The  size  of  an  ovarian  tumour  has  not,  by  itself,  appeared 
to  affect  the  result ;  but  size  and  solidity  together,  by  affecting 
the  length  of  the  incision  necessary  for  the  removal,  appear  to 
be  of  some  importance.  If  there  be  but  little  solid  or  semi- 
solid substance  present — which  is  generally  easily  discovered 
before  operation — large  adherent  cysts  holding  fifty,  sixty,  or 
seventy  pounds  of  fluid  may  be  removed,  after  the  contents  of 
the  cyst  have  been  evacuated,  through  an  opening  only  just 


size  253 

large  enough  to  admit  one  of  the  operator's  hands.  The  result 
of  such  cases  has  been  satisfactory ;  but  the  mortality  has  been 
greater  when  longer  incisions  have  been  necessary.  The  number 
of  inches  is  a  very  imperfect  mode  of  judging  of  the  length  of 
incision  in  these  cases  ;  for  in  a  small  woman  with  a  tumour  of 
moderate  size,  an  incision  of  eight  or  ten  inches  would  extend 
almost  from  sternum  to  pubes  ;  while  in  a  large  woman,  whose 
abdomen  is  greatly  distended  by  a  large  cyst,  an  incision  of 
this  length  may  be  made  below  the  umbilicus,  and  after  the 
contraction  of  the  abdominal  wall,  the  cicatrix  may  not  be  more 
than  three  or  four  inches  long ;  so  that,  in  examining  a  case  for 
operation,  it  becomes  important  to  judge  whether  a  cyst  or 
tumour  can  be  removed  by  an  incision  which  does  not  extend 
above  the  umbilicus.  If  this  can  be  done,  the  probability 
of  success  is  much  greater  than  when  it  becomes  necessary 
to  extend  the  incision  much  above  the  umbilicus.  On  this 
point  some  further  information  may  be  found  in  another 
chapter. 

ADHESIONS. 

In  296  cases  out  of  the  first  500  there  were  no  adhesions,  or 
they  were  so  slight  as  to  be  almost  unnoticed  ;  of  these  patients 
237  recovered  and  59  died,  the  mortality  being  19*93  per  cent. 
In  204  cases,  adhesions  were  very  extensive  :  of  these  patients 
136  recovered  and  68  died — a  mortality  of  33-33  per  cent. 
This  would  show  that  the  mortality  of  cases  where  there  are 
considerable  adhesions  is  about  13  per  cent,  greater  than  in 
cases  where  there  are  no,  or  only  trifling,  adhesions.  But  a 
more  careful  examination  of  each  case  appears  to  confirm  the  con- 
clusion at  which  I  arrived  some  years  ago,  that  adhesions  to  the 
abdominal  wall,  or  omentum  only,  have  but  little  influence 
upon  the  mortality,  and  that  the  importance  which  has  been 
attached  to  the  diagnosis  of  adhesions  before  operation  has  been 
greatly  and  unnecessarily  exaggerated.  At  the  same  time 
the  diagnosis  of  adhesions  within  the  pelvis  is  of  very  great 
importance,  as  the  attachments  to  the  bladder  or  rectum  may 
be  almost  inseparable  without  great  and  immediate  danger  to 
life.  The  same  may  be  said  of  attachments  to  the  liver, 
stomach,  spleen,  or  around  the  brim  of  the  pelvis,  the  separation 
of  which  would  endanger  the  iliac  vessels  or  the  ureters.     I 


254 


ADHESIONS 


formerly  believed  that  the  closeness  of  the  connection  be- 
tween the  uterus  and  the  ovarian  tumour  — in  other  words,  the 
length  of  the  pedicle— was  a  grave  matter,  as  upon  its  extent 
depended  the  possibility  of  keeping  the  end  of  the  secured 
pedicle  outside  the  peritoneal  cavity,  or  the  necessity  for 
leaving  it  within  this  cavity.  But  during  the  last  three  years, 
having  quite  abandoned  the  extra-peritoneal  treatment  of  the 
pedicle,  a  short  pedicle,  or  close  connection  between  cyst  and 
uterus,  only  becomes  important  in  leading  to  greater  difficulty 
in  securing  bleeding  vessels.  But  it  also  leads  to  the  necessity 
for  uniting  the  peritoneal  edges  of  the  divided  pedicle,  or 
separated  tumour,  by  suture,  in  order  to  avoid  dangers  which  will 
be  pointed  out  fully  in  the  chapter  on  the  operation. 

I  leave  the  remarks  made  upon  adhesions  in  1872  to  stand 
as  they  were  then  written  with  the  exception  of  the  last  two 
or  three  sentences.  The  table  which  I  now  give  illustrating 
the  same  subject  explains  the  very  little  modification  of  my 
opinion.  The  general  mortality  has  diminished  and  that  of  the 
cases  without  adhesions,  or  adhesions  only  to  the  parietes  and 
omentum,  remains  the  same,  as  will  be  seen  if  these  four  classes 
are  put  together.  But  the  mortality  among  the  bad  cases  is 
in  excess,  thus  increasing  somewhat  our  estimate  of  the  risk 
arising  from  the  intestinal,  cystic,  uterine,  and  pelvic  attach- 
ments. 

Table  showing  the  effect  of  Adhesions  upon  the  Results  of  Operations  in  the 
Second  500  Cases  of  Ovariotomy. 


Adhesions 

Cases 

Eecoveries 

Deaths 

Mortality 
per  cent. 

None     .         .         • 
Parietal        .... 
Parietal  and  omental   . 
Omental        .... 
Intestinal,  pelvic  and  others 

212 
61 
63 
62 

102 

183 
50 
51 
47 

•64 

29 
11 
12 
15 

38 

13-67 

18 

19 

24-19 

37-25 

500 

395 

105 

21 

Thus  far  as  regards  the  question  of  the  effect  of  adhe- 
sions upon  the  operation.  But  when  we  turn  to  that  of 
cure  of  the  miscellaneous  group  of  ovarian  sufferers  who 
present  themselves  to  us  for  help  the  case  is  very  different, 
for  to  the  deaths  after  ovariotomy,  really  attributable  to  adhe- 
sions, must  be  added  all  the  instances  of  failure  of  relief  by 


AGE 


255 


exploratory  incisions  and  incomplete  operations,  as  well  as  those 
which  are  dismissed  as  affording  no  chance  of  success  because 
of  the  hindrance  of  this  complication.  These  considerations 
add  to  the  gravity  with  which  we  ought  to  ponder  on  this 
phase  of  ovarian  disease,  and  lead  us  to  urge  with  more 
emphasis  how  essential  it  is  to  use  all  precautions  against 
the  formation  of  adhesions  ;  and  they  also  force  upon  our  atten- 
tion a  strong  argument  against  every  unnecessary  delay  in 
operating. 

AGE. 

In  order  to  examine  the  influence  of  the  age  of  a  patient 
upon  the  result  of  ovariotomy,  I  have  prepared  the  following 
tables,  which  show  the  ages  of  one  thousand  patients  upon 
whom  this  operation  was  completed,  with  the  result : — 

First  Five  Hundred. 


Ages 

Cases 

Recoveries 

Deaths 

Mortality  per  cent. 

From  15  to  20     . 

12 

12 

0 

0 

„       20  „   25     . 

52 

43 

9 

17-3 

25  „    30     . 

72 

54 

18 

25 

30  „    35     . 

69 

47 

22 

31-88 

35  „    40     . 

65 

48 

17 

26-15 

40  „   45     . 

74 

62 

12 

16-21 

45  „   50     . 

55 

37 

18 

32-72 

50  „    55     . 

62 

41 

21 

33-87 

55  „    60     . 

31 

22 

9 

29-03 

60  „    65     . 

6 

5 

1 

16-66 

65  „    70     . 

2 

2 

0 

0 

500 

373 

127 

25-4 

Second  Five  Hundred. 


Ages 

Cases 

Recoveries 

Deaths 

Mortality  per  cent. 

Under  15     . 

2 

2 

0 

From  15  to  20     . 

16 

14 

2 

12-5 

»      20  „  25     . 

45 

40 

5 

11-11 

„      25  „  30     . 

63 

50 

13 

20-63 

„      30  „  35     . 

72 

60 

12 

16-66 

„      35  „  40     . 

70 

55 

15 

21-42 

,,      40  „  45     . 

44 

36 

8 

18-18 

„      45  „  50     . 

54 

37 

17 

31-48 

„      50  „  55     . 

57 

45 

12 

21-05 

„      55  „  60     . 

38 

25 

13 

34-21 

„      60  „  65     . 

27 

23 

4 

14-81 

„      65  „  70     . 

10 

7 

3 

30 

Above  70    . 

2 

1 

1 

50 

500 

395 

105 

21 

256 


AGE 


Tlie  entire  Thousand. 


Ages 

Cases 

Recoveries 

Deaths 

Mortality  per  cent. 

Under  15    . 

2 

2 

0 

0 

From  15  to  20     . 

28 

26 

2 

7-14 

„      20  „  25     . 

97 

83 

14 

14-43 

„      25  „  30     . 

135 

104 

31 

22-96 

„      30  „  35     . 

141 

107 

34 

24-11 

„      35  „  40     . 

135 

103 

32 

23-7 

„      40  „  45     . 

118 

98 

20 

16-94 

„      45  „  50     . 

109 

74 

35 

3211 

„       50  „  55     . 

119 

86 

33 

27-73 

„      55  „  60     . 

69 

47 

22 

31-88 

„      60  „  65     . 

33 

28 

5 

15-15 

„      65  „  70     . 

12 

9 

3 

25 

Above  70     . 

2 

I 

1 

50 

1,000 

768 

232 

23-2 

I  have  divided  the  two  series  of  500  cases,  and  given  separate 
tables  for  them.  In  both,  the  small  mortality  shown  in 
patients  below  the  age  of  twenty-five  and  above  the  age  of 
sixty,  and  the  comparatively  high  mortality  between  those 
ages,  except  from  forty  to  forty-five,  are  remarkable. 

Neither  of  the  tables  has  any  important  variations.  The 
average  age  of  the  patients  proves  to  be  as  near  as  possible 
thirty-nine  years. 


MORTALITY    AT    DIFFERENT    AGES. 

In  reference  to  this  subject  Dr.  Ogle  writes  to  me  thus  : 
'  Among  the  3,414  deaths  ascribed  in  the  past  ten  years  either 
to  ovarian  dropsy  or  to  ovariotomy,  were  two  of  girls  under  15 
years  of  age,  and  seven  of  women  over  85  years  of  age.  The 
greatest  absolute  number  occurred  between  the  ages  of  45  and 
55,  and  next  to  this  came  the  decennia  on  either  side  of  this 
period  of  life.' 


MORTALITY    AT    DIFFERENT    AGES 


257 


Deaths. 


Ovarian  dropsy 

Ovariotomy 

1871 

194 

33 

1872 

200 

46 

1873 

207 

51 

1874 

168 

56 

1875 

343 

72 

1876 

327 

73 

1877 

355 

96 

1878 

367 

99 

1879 

255 

88 

1880 

298 

86 

Total  in  10  years 

2,714 

700 

The  actual  numbers  of  deaths,  however,  at  each  period 
of  life  give  by  themselves  no  information  as  to  the  com- 
parative fatality  of  this  disease  at  different  ages.  To  get  this 
we  must  take  into  account  the  different  numbers  of  women 
living  at  each  period.  Doing  this,  we  have  the  following  rates 
of  mortality  from  ovarian  dropsy  and  ovariotomy  per  million 
females  living  at  each  period  of  life  : — 


Period  of  life. 

Years 

Total  number  of  deaths 
in  ten  years 

Mean  annual  death-rate 

per  million  women  living 

at  that  period  of  life  * 

0 
10 
15 
20 
25 
35 
45 
55 
65 
75 
85  and  upwards 

0 

2 

63 

146 

527 

699 

868 

653 

358 

91 

7 

0 

2 

5 

13 

28 
49 
79 
87 
82 
56 
28 

From  10  years  upwards 

3,414 

37 

*  N.B.— For  these  rates  the  nearest  whole  number  is  taken,  so  as  to  avoid  decimals. 

'It  thus  appears  that  the  time  of  life  when  this  disease  is 
most  fatal,  that  is,  causes  most  deaths  in  proportion  to  the 
number  living,  is  from  55  to  65,  and  the  next  fatal  periods  are 
the  decennia  on  either  side  of  this.' 


258 


CONJUGAL    CONDITION 


CONJUGAL    CONDITION. 

Of  the  first  five  hundred  patients  there  were — 


Cases 

Kecoveries 

Deaths 

Mortality  pe 

Married  . 

.     279 

204 

75 

26-84 

Single 

.     221 

169 

52 

23-52 

500 


373 


127 


254 


Second  Five  Hundred. 


Married  . 

.     290 

235 

55 

18-96 

Single 

.     210 

160 

50 

23  8 

500 


39c 


105 


The  whole  Thousand. 


1,000 


768 


232 


21 


Married  . 

.     569 

439 

130 

22-84 

Single 

.     431 

329 

102 

23-66 

23-2 


This  shows  that   the   mortality  was  nearly  equal   among 
married  and  unmarried  women  at  all  ages. 


SOCIAL   CONDITION. 

I  need  not  say  that  the  results  of  operations  in  hospital 
and  private  practice  are  affected  by  many  other  causes  besides 
the  social  condition  of  the  patients  ;  but  it  may  be  of  some 
value  in  ascertaining  the  effect  of  modes  and  habits  of  life  of 
patients  upon  the  mortality  of  ovariotomy  to  state,  that  in  the 
first  five  hundred  cases  there  were — 


Cases 

Kecoveries 

Deaths 

Mortality  per  cent. 

Total  hospital  cases 

.     240 

176 

64 

26-66 

Total  private  cases 

.     260 

197 

63 

24-23 

500  373  127 

that  in  the  second  five  hundred  cases  there  were — 

Total  hospital  cases        .     163-  128  35 

Total  private  cases  .     337  267  70 


500 


395 


105 


25-4 


20-85 
20-77 


21 


SOCIAL    CONDITION  259 

It  will  be  seen  that  the  figures  do  not  correspond  in  the  two 
series  of  cases.  In  the  first  five  hundred,  the  mortality  was 
rather  above  the  average  among  the  hospital  patients,  and 
rather  below  it  among  the  cases  operated  on  at  their  homes  or 
in  nursing  houses.  But  the  difference  is  not  very  great,  and 
may  perhaps  be  accounted  for  by  the  facts  that  most  of  my 
early  operations  were  done  in  what  was  called  hospital,  without 
being  really  more  than  hired  rooms  wanting  all  the  accessories 
successively  obtained  in  after-years ;  that  the  nursing  was 
intrusted  to  inexperienced  women,  and  that  the  after-treatment 
lacked  the  aptitude  and  knowledge  which  we  have  since 
acquired.  In  the  second  series,  the  rate  of  death  is  so  nearly 
equal,  that  it  almost  becomes  a  matter  of  congratulation  for  our 
poorer  patients,  when  we  compare  the  results  with  the  belief 
formerly  entertained  by  some  writers  that  deaths  have  been 
chiefly  among  poor  women,  and  that  this  is  not  accidental. 
My  experience  certainly  does  not  support  the  conclusion  that 
'  the  social  position  of  the  patient  has  a  good  deal  to  do  with  the 
result.'  Some  few  have  been  ill-fed  and  overworked,  but  I  can 
scarcely  count  among  my  whole  list  of  403  hospital  cases  more 
than  a  very  few  who  could  actually  be  ranked  as  paupers,  and 
scarcely  one  without  either  home,  husband,  or  occupation : — 

The  whole  thousand  cases  stand  thus : — 


Cases 

Recoveries 

Deaths 

Mortality  per  cent. 

Hospital  . 

.     403 

304 

99 

24-56 

Private     . 

.     597 

464 

133 

22-27 

1,000  768  232  23-2 

Many  of  these  private  operations  have  been  performed  in 
the  houses  now  becoming  common  in  London,  where,  under 
the  name  of  '  Nursing  Institution,'  or  4  Home  for  Invalids,' 
or  some  such  title,  it  is  intended  that  a  patient  shall  obtain  the 
conjoint  advantages  of  a  hospital  and  of  home  or  private  apart- 
ments. There  can  be  no  doubt  of  the  advantages  of  such 
houses  to  patients,  or  of  the  great  convenience  to  the  surgeon, 
provided  the  management  is  good.  But  they  must  always  be 
open  to  the  objection  of  subjecting  one  patient,  more  or  less, 
to  the  influence  of  others  in  adjoining  rooms  or  in  the  same 
house.  And  it  is  interesting  to  notice  that,  whereas  in  a  series 
of  300  cases  the  mortality  in  private   houses  was   25*38    per 

s  2 


260  NURSING    HOMES 

cent.,  and  in  the  Samaritan  Hospital  25*60  per  cent.,  it  was 
26*66  per  cent,  in  the  nursing  homes.  The  numbers  are  as 
follows  : — 

Cases  Recoveries  Deaths  Mortality  per  cent. 
Private  houses        .         .     130                 97                33  25-38 

Samaritan  hospital  .     125  93  32  25-60 

Nursing  homes  45  33  12  26-66 

I  may  add  that  these  houses  were  situated  in  Upper  Wimpole 
Street,  Great  Marylebone  Street,  Manchester  Street,  Maryle- 
bone  Road,  and  Blandford  Square,  positions  not  very  different 
from  that  of  the  Samaritan  Hospital.  I  am  convinced  that 
some  of  the  deaths,  both  in  hospital  and  in  the  nursing  es- 
tablishments, have  been  due  to  the  injurious  influence  of  other 
patients  upon  the  subject  of  the  operation;  an  influence  which 
would  not  have  been  felt  in  a  private  house.  Apart  from  all 
question  of  antiseptics,  my  belief  is  that,  in  the  one  case,  if  any 
important  peritonitis  follow  the  operation,  the  inflammation  is 
almost  always  local,  not  attended  by  much  effusion  of  serum, 
nor  by  elevation  of  temperature  or  other  signs  of  fever  or  blood- 
poisoning  ;  whereas,  under  unfavourable  sanitary  conditions, 
the  inflammation  is  diffused,  is  accompanied  by  the  rapid 
effusion  of  a  considerable  amount  of  fluid,  with  great  elevation 
of  temperature  and  other  indications  of  septicaemia.  I  am 
becoming  more  and  more  doubtful  if  we  ever  see  this  latter 
chain  of  symptoms,  either  in  hospital  or  in  healthy  houses,  if 
the  patients  are  kept  quite  free  from  the  access,  by  contagion 
or  infection,  of  the  poisonous  material — solid,  liquid,  or  gaseous 
— which  acts  as  certainly  as  an  inoculated  particle  of  smallpox 
or  vaccine  virus,  or  as  the  inspiration  of  an  infective  atmosphere 
in  scarlatina,  and  from  which  the  patient  is  absolutely  safe  in 
the  absence  of  the  poison. 

INFLUENCE   OF  SEASON. 

In  the  first  200  cases  the  mortality  was  rather  lower  in  the 
spring  and  summer  than  in  the  autumn  and  winter  months.  It 
was  highest  in  December  and  January,  but  it  was  lowest  in 
November  and  March.  Hence,  looking  to  the  small  difference 
between  the  mean  temperatures  of  November  and  December 
the  months  of  lowest    and    highest    mortality,    or  between 


INFLUENCE    OF    SEASONS  261 

January  and  March  —  the  months  of  the  next  highest  and 
lowest  mortality,  it  seems  probable  that  the  result  of  ovari- 
otomy is  more  influenced  by  some  exceptional  atmospheric  and 
climatic  conditions  than  by  the  season  when  it  is  performed. 
And  this  opinion  is  confirmed  by  the  results  of  the  300 
cases  which  succeed  the  first  200,  for  in  the  third  hundred 
the  greatest  mortality  was  in  November,  while  in  the  fourth 
and  fifth  it  was  pretty  equally  distributed  over  the  whole 
year.  This  is  all  that  I  was  able  to  say  in  1872  on  the 
influence  of  seasons,  and  no  more  precise  deductions  can  be 
drawn  from  the  numbers  of  deaths  occurring  in  the  various 
months  of  the  eight  years  in  which  I  did  my  second  500 
operations.  For  if  I  took  the  bare  figures  I  should  have  to 
declare  that  the  greatest  numbers  died  in  May,  July,  and  June, 
there  being  11,  12,  and  15  deaths  debited  to  these  months 
respectively  for  all  the  eight  years.  But  then  it  must  be  re- 
membered that  this  quarter  of  the  year  is  the  time  of  most 
active  work  in  London,  that  I  have  never  quitted  my  post  at 
that  season,  and  that  more  cases  have  been  sent  to  me  then 
than  during  any  other  three  consecutive  months.  February 
and  October  only  can  compete  with  them.  I  now  speak  of  all 
the  eight  Mays  and  other  months  collectively,  1872-1880.  In 
the  Mays  I  have  operated  53  times ;  in  the  Junes  52  times ; 
and  in  the  July  months  58  times.  The  February  operations 
were  52  and  the  October  50.  The  other  months  varied  from 
10  to  47.  But  there  are  holidays  to  be  taken  into  account, 
and  I  have  always  gone  away  for  parts  of  August  and  Septem- 
ber, and  sometimes  in  December  aud  January.  The  actual 
number  of  deaths  tells  only  in  general  that  I  was  more  or 
less  busy  and  did  a  fluctuating  number  of  operations.  It 
throws  no  light  upon  the  question  of  the  fatality  of  the 
seasons. 

Nor  if  we  look  at  it  from  another  point  of  view  does  it 
become  much  clearer.  I  give  a  table  showing  the  number  of 
the  operations,  with  results  and  average  mortality,  as  they 
were  done  in  the  several  sets  of  months  in  the  consecutive 
eight  years. 


262 


INFLUEJJCE 


Months 

Cases 

Deaths 

Mortality  percent. 

January 

February 

March 

35 

52 
40 

9 

5 

11 

2571 
961 

27-5 

April 
May. 
June 

45 
53 

52 

9 
11 
15 

20 

2075 

28-84 

July. 

August 

58 
25 

12 
4 

20-68 
16 

September 
October     . 

10 
50 

2 
10 

20 
20 

November 

47 

7 

14-89. 

December 

33 

10 

30-3 

From  this  it  would  seem  that  the  most  favourable  months 
are  February,  August,  and  November  ;  that  April,  May,  July, 
September,  and  October  have  an  average  very  nearly  correspond- 
ing with  that  of  my  second  series ;  and  that  the  greatest 
fatality  has  happened  in  January,  March,  June,  and  December. 

The  first  half  of  the  year  gives  a  percentage  of  21*66,  and 
the  second  half  of  20*17  ;  the  six  summer  months  21*02,  and 
the  six  winter  months  20*23.  The  half  years,  therefore,  taken 
either  as  they  run,  dividing  the  seasons,  or  as  sets  of  summer 
and  winter  months,  may  really  be  regarded  as  identical  in  their 
results.  But  why  February  and  November,  which  are  always 
talked  of  as  times  of  unhealthiness,  should  stand  out  in  such 
contrast  with  general  impressions,  and  why,  too,  such  months 
as  June  and  December,  so  opposite  in  all  their  conditions, 
should  so  nearly  approach  each  other  in  their  death-rate,  is 
inexplicable.  If  it  had  so  turned  out  that  my  proportion  of 
deaths  was  larger  when  I  did  most  operations,  I  should  perhaps 
have  blamed  myself,  and  fancied  that  multiplicity  of  engage- 
ments was  the  occasion  of  some  oversight  or  carelessness  ;  but 
it  is  not  so.  My  smallest  mortality  was  when  there  was  the 
accumulation  of  52  cases  in  the  eight  February  months,  and 
my  greatest  mortality  when  there  were  only  33  operations  done 
in  the  same  space  of  time,  that  is,  in  the  eight  Decembers. 

In  looking  over  all  these  figures  and  remarks  on  the  condi- 
tions affecting  the  probable  success  of  operations,  there  is  this 
qualification  to  be  thought  of.  The  field  of  observation  from 
which  they  are  drawn  is  after  all  very  limited.  It  is  the  ex- 
perience of  one  man  and  of  one  locality.  It  is  true  that  what 
happened  to  him  may  happen  to  others.     But  personality  has 


OF   SEASONS  263 

a  great  deal  to  do  with  the  outcome  of  a  man's  work,  and  when 
that  work,  as  in  ovariotomy,  is  not  single-handed,  the  assistance 
that  he  gets  has  not  much  less  influence.  As  an  individual  I 
have  but  little  changed  during  the  twenty  years,  and  it  is  both 
a  duty  and  a  pleasure  to  acknowledge  that  upon  the  whole  I 
have  been  ably  and  conscientiously  seconded. 

I  have  done  what  it  seemed  possible  to  do  under  the  circum- 
stances ;  that  is,  I  have  gathered  the  facts  together  and  have 
tested  them  to  see  whether  they  would  yield  any  data  for  form- 
ing opinions  which  I  might  announce  safely  and  beneficially. 
But,  curious  as  is  my  information,  strange  as  are  the  results 
which  the  calculations  founded  upon  it  present,  the  guidance 
to  be  gained  is  ambiguous  because  the  area  for  collection  is, 
relatively  to  the  subject,  too  contracted;  and  it  is  not  by  the 
energy,  or  in  the  lifetime,  of  one  man  that  it  can  be  sufficiently 
enlarged  and  its  products  garnered.  The  combined  action  of 
many  observers  in  every  variety  of  social,  territorial,  climatic, 
and  professional  conditions,  extending  over  adequate  time  and 
numbers,  must  be  brought  to  bear  upon  the  subject  before  we 
can  formulate  dogmatically  the  laws  which  determine  the  results 
of  our  operations. 

But  in  the  meanwhile  the  great  principles  which  lie  at  the 
foundation  of  surgical  science  remain  unchangeable.  It  is  the 
patients  that  vary,  and  to  such  an  extent,  that  though  they  may 
be  roughly  thrown  into  classes,  the  peculiarities  are  so  great  that 
everyone  must  have  her  separate  consideration.  By  continuous 
habitude  in  common  with  all  professional  experts,  one  acquires 
a  certain  power  of  forecasting,  and  in  a  large  number  of  cases  I 
feel  that  I  can  read  the  doom  or  augur  well  of  my  subject. 
But  this  is  not  a  communicable  faculty,  and  must  be  waited  for. 
It  ought  not,  and  it  does  not,  stand  in  the  way  of  putting  into 
practice  the  lesson  that  is  to  be  learnt  from  all  that  has  just 
been  said — that  we  must  deal  with  every  case  as  it  comes  before 
us  as  if  it  were  unique,  and  must  concentrate  attention  upon 
the  actual  circumstances.  We  must  gather  up  the  threads  of 
the  personal  history  of  the  patient,  acquaint  ourselves  with  the 
peculiarities  of  her  moral  and  physical  condition,  inform  ourselves 
by  every  means  of  investigation  of  the  characteristics  of  the  local 
disease,  surround  her  with  every  accessory  that  our  current  know- 
ledge suggests  as  conducive  to  her  safety,  use  every  precaution 


264  CONTRA-INDICATIONS 

and  expedient  that  practice  and  study  have  taught  us  in  our 
operative  work,  and  lead  on  to  her  recovery  if  possible  by  doing  no 
mischief  and  meeting  every  complication  quickly  and  to  the  best 
of  our  skill.  If  so,  and  at  the  same  time  we  note  all  changes 
and  accidents  in  external  circumstances  coincident  with  the 
varying  progress  of  our  patient  and  the  ultimate  result  of  our 
efforts,  we  may  be  satisfied  that  we  have  done  all  that  humanity 
and  professional  responsibility  can  demand  from  us  as  practi- 
tioners, and  have  contributed  our  share  to  the  future  elucidation 
of  the  problems  which  lie  before  us  and  await  solution  at  the 
hands  of  the  coming  generation. 

CONTRA-INDICATIONS. 

As  a  general  rule,  any  existing  disease  which  in  its  natural 
course  would  prove  fatal  to  the  patient,  or  would  influence 
her  constitution  in  such  a  manner  as  to  render  her  recovery 
very  unlikely,  or  other  serious  surgical  operations  inadmissible, 
should  also  forbid  ovariotomy.  It  ought  not  to  be  resorted 
to  in  individuals  suffering  from  cancer,  far-advanced  tubercu- 
losis or  scrofula,  syphilis,  important  diseases  of  the  heart,  or 
in  cases  where  this  organ  has  been  displaced  by  the  tumour, 
and  at  the  same  time  has  been  fixed  in  its  abnormal  site 
by  adhesions  which"  would  retain  it  in  its  position  even  after 
the  removal  of  the  ovary  ;  diseases  of  the  brain  and  of  the 
nervous  centres,  of  the  liver,  spleen,  and  kidneys ;  ulcers  of  the 
stomach  and  diseases  of  the  alimentary  canal,  which  permanently 
impair  general  nutrition  ;  ascites  in  consequence  of  liver  com- 
plaint, of  disease  of  the  heart,  or  degeneration  of  the  kidneys. 
Scurvy,  anaemia,  and  other  blood  diseases,  hectic  fever,  great 
weakness  and  extreme  emaciation  from  advanced  age  or  im- 
paired nutrition,  would  lead,  if  not  to  absolute  prohibition,  to  a 
very  unfavourable  opinion  as  to  the  probable  result. 

But  scarcely  ever  will  the  judgment  of  the  surgeon  be  so 
severely  tested  as  in  estimating  the  value  and  importance  of 
many  of  the  above-mentioned  contra-indications,  whether  any 
one  is  by  itself  so  serious  as  to  preclude  surgical  interference, 
or  is  merely  a  consequence  of  the  local  disease.  This  may  be 
instanced  by  one  of  my  cases  where  all  the  symptoms  of  far- 
advanced  tuberculosis  were  present — cough,  hectic  fever,  high 


CONTRA-INDICATIONS  265 

temperature,  and  rapid  pulse — which  all  disappeared  after  ex- 
tirpation of  the  ovarian  tumour.  The  pulse  fell  from  108  to 
88,  the  temperature  from  101*4  °F.  to  its  normal  range ;  cough 
was  no  longer  troublesome.  It  may  be  added  that  the  cyst 
contained  genuine  tubercular  deposits,  was  thin-walled,  and 
very  fragile. 

The  operation  ought  not  to  be  performed  when  the  tumour  is 
in  an  advanced  stage  of  cancerous  degeneration.  But  so  many  in- 
stances of  recovery  after  extirpation  of  what  was  pronounced  to 
be  cancer  are  well  known,  that  there  must  be  more  than  bare 
suspicion  to  set  aside  the  operation.  Cancer  of  the  ovaries  is 
supposed  to  occur  most  frequently  after  the  change  of  life  ;  but 
cases  have  been  mentioned,  in  another  chapter,  of  this  disease  in 
a  young  girl,  and  in  middle-aged  women.  Such  tumours  often 
form  extensive  and  intimate  adhesions,  infiltrate  the  surround- 
ing tissues,  and  attack  the  neighbouring  organs,  with  which 
they  form  at  an  advanced  stage  of  the  degeneration  one  conflu- 
ent mass.  In  most  cases,  their  extirpation,  if  attempted,  would 
meet  with  insurmountable  difficulties  ;  and  should  the  operation 
be  terminated  and  the  patient  recover  from  it,  the  disease 
would  sooner  or  later  attack  some  other  part  or  organ.  Ascites 
generally  accompanies  malignant  disease  of  the  ovaries,  and 
both  ovaries  are  usually  affected  at  the  same  time. 

The  presence  of  ascites  needs  not  deter  from  the  operation, 
provided  it  be  due  to  escape  of  fluid  from  the  cyst,  or  is  brought 
on  by  the  mechanical  irritation  of  the  peritoneum  by  the 
tumour.  If,  however,  it  is  caused  by  disease  of  heart,  liver,  or 
kidneys,  these  conditions  almost  always  forbid  the  operation. 
The  complication  of  pregnancy  with  ovarian  disease,  and  its 
bearing  on  ovariotomy,  are  treated  of  in  a  subsequent  chapter. 


2G6  TIME    FOR   OPERATION 


CHAPTEK   VII. 

PREPARATION   OF   A   PATIENT   FOR   OVARIOTOMY;    DUTIES   OF   THE 
NURSE;    DESCRIPTION   OF   NECESSARY   INSTRUMENTS. 

It  by  no  means  follows  that  the  state  of  robust  health  is  one 
so  favourable  for  operation,  as  that  of  a  patient  more  or  less 
accustomed  to  the  quiet  and  habits  of  a  sick  room.  A  young, 
strong,  healthy  person,  much  of  whose  time  is  passed  in  open- 
air  exercise,  does  not  bear  so  well  the  enforced  quiet  of  a  sick 
room  as  the  patient  who  has  become  gradually  habituated  to  it. 
And  it  is  perhaps  one  of  the  most  difficult  questions  which  the 
surgeon  has  to  determine,  whether  the  patient  is  suffering 
enough  in  general  condition  to  warrant  him  in  recommending 
an  operation  necessarily  attended  with  serious  risk  to  life,  and 
yet  not  so  far  broken  down  by  the  progress  of  the  disease  as  to 
lessen  the  chances  of  recovery  after  operation.  Every  case 
must  be  judged  by  its  own  peculiarities ;  not  those  only  which 
relate  to  the  physical  condition  of  the  patient,  but  the  various 
moral,  mental,  and  social  influences  which  have  so  constantly 
to  be  considered  in  daily  practice,  and  which  so  materially 
affect  the  results  of  any  operation.  For  instance,  an  unmarried 
girl  with  ovarian  disease  is  often  so  distressed  by  the  suspicions 
which  her  appearance  excites,  that  she  must  be  relieved  earlier 
than  a  married  woman  of  the  same  size  need  be  ;  and  a  girl 
engaged  to  be  married,  and  naturally  unwilling  to  marry  as  an 
invalid,  may  claim  with  good  reason  earlier  aid  from  surgery 
than  one  not  so  pledged.  The  same  would  hold  good  with  a 
wife  wishing  to  travel  with  her  husband,  or  to  join  him  in 
some  distant  part  of  the  world.  On  the  other  hand,  there  are 
family  circumstances  which  world  properly  delay  operation  till 
the  last  possible  moment.  Children  may  be  dependent  on  the 
annuity  of  the  mother,  whose  life  should  not  be  subject  to  the 
additional  risk  of  the  operation  until  it  is  imperatively  called 


TREATMENT  BEFORE  OPERATION  267 

for  by  the  severity  of  her  sufferings.  In  many  cases  such 
considerations  have  guided  me  in  operating  either  earlier  or 
later  than  one  would  do  if  only  obliged  to  regard  what  was 
best  for  the  bodily  welfare,  and  able  altogether  to  ignore  the 
affections,  interests,  and  circumstances  of  patients. 

One  condition  which  certainly  requires  correction  before 
the  operation  is  undertaken,  is  that  common  one  where  only  a 
small  quantity  of  highly  concentrated  urine,  depositing  mixed 
urates  in  abundance,  is  passed.  If  ovariotomy  be  performed 
on  a  patient  in  this  condition,  a  serious  amount  of  kidney 
congestion,  with  symptoms  almost  amounting  to  ursemic  fever, 
is  almost  certain  to  follow  the  operation.  Before  undertaking 
it,  therefore,  it  may  be  necessary  to  gain  time  by  tapping. 
Whether  or  no  this  may  be  necessary,  warm  baths  or  vapour 
baths,  to  promote  free  cutaneous  secretion,  somethiDg  to  secure 
a  free  daily  action  of  the  bowels,  and  some  of  the  alkaline  car- 
bonates, largely  diluted,  will  most  likely  greatly  improve  the 
condition  of  the  patient.  Nothing  tends  so  rapidly  to  clear 
the  urine  as  lithia.  One  or  two  bottles  of  lithia  water — either 
the  liquor  Utilise  effervescens  of  the  Pharmacopoeia,  or  the  lithia 
water  of  the  shops,  which  contains  five  or  ten  grains  of  citrate 
of  lithia  to  each  bottle,  or  from  five  to  ten  grains  of  the  citrate 
or  carbonate  of  lithia,  dissolved  in  a  full  proportion  of  simple 
or  aerated  water,  two  or  three  times  a  day,  generally  lead  to  a 
more  abundant  secretion  of  urine  which  is  free  from  deposit. 
Sometimes  it  is  a  good  plan  to  combine  the  carbonates  of  lithia, 
potash,  and  soda  together,  and  it  may  be  desirable  to  give  iron 
at  the  same  time.  A  draught  of  five  grains  of  tartrate  of  iron, 
five  of  carbonate  of  lithia,  and  ten  each  of  the  bicarbonates  of 
potash  and  soda,  with  a  few  drops  of  chloric  ether,  two  or  three 
times  a  day,  has  often  appeared  to  me  to  be  of  great  service. 
Simpson  was  strongly  in  favour  of  a  course  of  perchloricle  of 
iron  before  ovariotomy,  or  any  other  serious  surgical  operation. 
He  thought  it  so  altered  the  condition  of  the  blood  as  to  make 
pyaemic  fever  or  septicaemia  much  less  liable  to  occur.  A  change 
to  the  seaside  or  country  will,  of  course,  assist  the  restorative 
action  of  medicines  ;  and  if  the  patient  is  brought  from  the 
country  it  may  be  as  well  to  arrange  for  the  performance  of  the 
operation  at  as  early  a  period  as  possible,  before  the  influences 
of  town  life  have  had  time  to  prove  injurious. 


268  PLACE   FOR   CTEKATIOX 

The  place  where  the  operation  is  performed  ought  to  be 
healthy,  and,  as  time  is  generally  at  our  command,  there  can 
be  no  excuse  for  putting  or  leaving  the  patient  in  an  unhealthy 
house  or  district.  If  she  lives  in  a  healthy  part  of  the  country 
and  can  be  treated  there,  it  would  be  positive  cruelty  to  bring 
her  to  an  unhealthy  part  of  town,  or  to  expose  her  to  the  influ- 
ences of  a  large  general  hospital.  Even  in  the  same  town,  or 
in  the  same  district  of  large  cities,  better  results  have  been 
obtained  in  private  houses  and  in  small  hospitals,  where  the 
patient  occupies  a  room  alone,  than  in  large  general  hospitals, 
where  she  must  share  a  ward  with  other  patients,  and  may  be 
subject  to  the  influences  of  dissecting  students.  At  the  Sama- 
ritan Hospital,  where  there  are  seldom  more  than  twenty  and 
never  more  than  thirty  patients,  and  where  every  patient  sub- 
jected to  ovariotomy  has  a  room  and  nurse  to  herself  for  a  week 
after  operation,  my  own  results  have  at  times  shown  a  consider- 
ably greater  mortality  than  in  private  houses ;  and  I  have  found 
in  a  private  nursing  institution,  where  each  patient  had  also  a 
separate  room,  that  the  mortality  was  as  great  as  in  the  Sama- 
ritan Hospital.  In  the  fourth  series  of  one  hundred  cases  the 
mortality  in  private  practice  was  only  14  per  cent.,  while  in 
hospital  it  was  31  per  cent.  But  on  the  whole  series  of  one 
thousand  cases  there  is  only  a  difference  of  little  more  than  2 
per  cent,  in  favour  of  cases  in  private  practice.  In  the  first  one 
hundred  the  advantage  was  in  favour  of  the  hospital  as  much 
as  10  per  cent.,  and  in  the  fifth  hundred  fully  7  per  cent,  in 
favour  of  the  private.  And  it  is  well  worthy  of  remark  that 
the  periods  of  good  and  indifferent  results  in  hospital  have 
corresponded  with  improvements  in  its  sanitary  condition. 
After  emptying  the  hospital  for  a  month  or  more,  and  thoroughly 
cleansing,  painting,  and  lime  washing  the  wards,  a  period  of 
almost  uninterrupted  success  has  followed.  Then  what  was 
called  '  a  run  of  bad  luck  '  set  in,  clearly  attributable  to  crowd- 
ing, some  neglect  in  purifying  bedding,  or  to  contagion  or 
infection.  Another  thorough  cleansing  again  led  to  more 
favourable  results,  and  in  the  six  months  from  December  1871, 
after  complete  repairs,  to  July  1872,  of  twenty- four  cases,  only 
two  died  and  twenty-two  recovered.  But  this  mortality, 
though  larger  than  that  in  private  practice  now,  is  very  much 
smaller  than  anything  yet  attained  in  any  large  general  hospital. 


VENTILATION  AND  FURNITURE  269 

If  we  could  obtain  all  the  favourable  conditions  of  a  room  in  a 
private  house,  in  a  healthy  country  situation,  there  can  be  no 
doubt  that  the  mortality  would  be  much  smaller  than  the  most 
favourable  results  hitherto  attained.  And  the  question  seriously 
presents  itself  whether  ovariotomy  or  any  other  surgical  opera- 
tion, attended  with  risk  to  life,  should  ever  be  performed  in  a 
large  general  hospital,  in  a  large  town,  except  under  such  cir- 
cumstances as  would  render  removal  to  the  country  or  to  a 
suburban  cottage  hospital  more  dangerous.  Of  late  years,  the 
extension  of  antiseptic  treatment,  especially  in  hospital  practice, 
has,  however,  so  greatly  reduced  hospital  mortality  that  the 
opinion  just  expressed  will  probably  be  considerably  modified 
in  the  future. 

The  ward  or  room,  whether  in  a  small  hospital  or  in  a 
private  house,  should  be  well  provided  with  means  for  keeping 
up  a  continual  and  sufficient  ventilation,  without  exposing  the 
patient  to  currents  of  cold  air,  and  the  temperature  should  be 
regulated  by  an  open  fire.  In  a  building  specially  constructed 
for  the  purpose,  it  would  be  perfectly  easy  to  keep  up  a  constant 
current  of  fresh  air,  at  any  temperature  required,  night  and 
day ;  but  the  knowledge  of  the  architect  and  the  art  of  the 
builder  are  very  far  behind  the  scientific  teaching  of  the  day, 
and  what  is  theoretically  easy  in  warming  and  ventilating  a 
house  has  probably  never  yet  been  done  well.  All  unnecessary 
furniture  should  be  removed  from  the  room,  particularly  dusty 
woollen  curtains  and  carpets.  Instead  of  a  bed  with  heavy 
draperies,  two  iron  bedsteads  should  be  provided,  not  more 
than  three  feet  six  inches  wide,  so  that  the  patient  can  be 
reached  equally  well  from  either  side,  and  may  be  lifted  from 
one  bed  to  the  other,  if  desirable.  A  horsehair  mattress  is 
cooler  and  firmer  than  a  feather  bed,  and  therefore  preferable, 
and  one  of  the  many  forms  of  open  iron  spring  bedsteads  are 
far  safer  than  the  old  sacking  and  wool  or  straw  mattress  under 
the  horsehair.  The  covering  ought  to  be  light  but  warm  ;  and 
no  one  should  be  allowed  in  the  room  but  the  patient  and  her 
nurse. 

The  nurse  has  a  very  important  influence  on  the  result  of 
ovariotomy.  Much  depends  on  her  scrupulously  regarding  all 
the  essentia]  precautions,  and  judiciously  managing  for  the 
comfort  and  encouragement   of  the  patient,  up  to  the  time  of 


270  NURSES 

the  operation ;  and  the  after  treatment  can  be  altogether 
marred  by  any  failure  of  discipline,  or  neglect  in  fulfilling 
every  little  point  of  the  duties  entrusted  to  her.  What  is 
especially  wanted  in  a  nurse  for  this  kind  of  work  is  a  calm, 
quick,  decided  way  of  doing  it ;  an  intelligent  understanding 
of  its  nature;  a  readiness  in  comprehending  the  instructions 
given ;  punctuality  and  exactness  in  carrying  them  out ;  and 
a  discriminating  carefulness  in  observing  and  reporting  all 
that  passes  under  her  notice,  and  that  may  be  of  import- 
ance to  the  surgeon  in  judging  of  the  progress  or  regulating 
the  treatment  of  the  case. 

There  is  at  the  present  time  a  fair,  free,  and  remunerative 
field  for  the  exercise  of  these  combined  qualities,  which,  after 
all,  are  not  so  rare  as  might  be  supposed,  though  they  de- 
velop more  notably  in  a  stratum  of  society  where  one  would 
not,  at  first  thought,  have  expected  to  find  them.     As  a  rule, 
ladies  in  search  of  an  occupation  for  a  livelihood,  or  who  take 
to  it  because  they  know  not  what  else  to  do,  or  who  fall  into  it 
by  sentiment  or  accident,  seldom  succeed  in  nursing  well.    There 
is  generally  a  lurking  sense  of  degradation  which  takes  the 
spring  out  of  their  work,  and  throws  over  it  an  undefinable  but 
appreciable  air  of  taskiness  which  has  its  influence  both  upon 
patient  and  surgeon.     Whereas  for  the  most  part  a  nurse  who 
has  changed  from  the  business  of  ordinary  domestic  service  feels 
that-  she  is  making  a  step  upward  in  life,  and  goes  about  what 
she  has  to  do  with   a  kind  of  professional  pride  and  personal 
interest  in  its  success.     A  young  woman  of  this  class  has  already 
fallen  into  habits  of  cleanliness,  order,  and  submission ;  she 
knows  from   experience  in  her  own  family  the   way  the  poor 
manage   for   themselves,   and   she   has   had    opportunities   of 
observing  the  wants  and  indulgences  which  slide  into  the  list 
of  necessaries  among  the  luxurious.     She  has  acquired  in  her 
calling   a   certain    dexterity  in   the  arranging,   handling,  and 
cleansing  all  the  usual  utensils  and  appliances  of  a  sick-room, 
and  a  sort  of  chamber  ease  and  conformity  in  her  movements 
which  only  come  after  practice  in  household  duties.     Her  mind, 
too,  from  acting  habitually  under  orders,  and  in  obedience  to 
rules,  and  under  a  light  weight  of  responsibility,  has  generally 
become  pliant,  receptive,  responsive,  and    forecasting.     It  is 
comparatively  easy  to  graft  on  a  stock  so  prepared  the  addi- 


DUTIES    OF    A    NUUSE  271 

tional  qualifications  required  for  making  a  good  nurse,  and  it 
certainly  is  worth  the  while  for  any  one  much  engaged  in  opera- 
tions of  the  kind  we  are  dealing  with,  to  train  in  his  own  ways 
those  whose  co-operation  he  wants,  both  for  his  own  comfort 
and  the  welfare  of  his  patients.  The  passive,  confiding  docility 
of  women  after  ovariotomy,  who  find  themselves  subject  to 
the  good  understanding  which  exists  between  a  competent  nurse 
and  the  surgeon  she  is  serving  under,  is  in  marked  contrast 
with  the  keen,  anxious  watchfulness  and  feverish  fidgetiness  of 
others  less  fortunate  in  their  attendants,  and  their  progress 
towards  convalescence  is  promoted  or  retarded  in  such  a  way 
as  to  make  very  clear  how  much  the  style  of  nursing  has  to 
do  with  it. 

No  nurse  should  be  entrusted  with  the  care  of  a  patient 
after  ovariotomy  unless  she  is  well  able  to  use  the  female 
catheter  without  uncovering  the  body  and  exposing  it  to  chill. 
She  should  use  the  catheter  every  six  or  eight  hours,  or  as 
much  oftener  as  the  patient  may  wish,  and  should  preserve  the 
urine,  but  not  in  the  sick-room,  for  the  examination  of  the 
surgeon.  She  should  also  be  well  practised  in  clearing  the 
rectum  by  injections,  and  expert  in  giving  medicine  or  food  by 
it  when  necessary.  She  should  know  the  danger  of  bed-sores, 
and  the  mode  of  avoiding  them.  She  should  understand  the 
importance  of  thoroughly  cleansing  and  freeing  from  every 
particle  of  sand,  and  deodorizing  or  disinfecting,  every  sponge 
which  is  to  be  used  during  or  after  the  operation,  and  on  any 
day  of  operation  she  should  have  at  least  twenty  soft  sponges, 
when  moist  about  the  size  of  the  double  fist,  not  quite  but 
nearly  dry,  before  the  arrival  of  the  surgeon.  Here,  however, 
I  should  say  that  very  few  nurses  can  be  entrusted  with  this 
duty,  and  I  always  see  myself  that  the  sponges  are  as  pure  as 
they  possibly  can  be  made  before  every  operation.  She  should 
also  have  prepared  several  slips  of  adhesive  plaster,  about  two 
inches  broad,  and  long  enough  to  more  than  half  encircle  the 
body ;  a  supply  of  lint  thymol  or  iodoform  gauze,  and  some 
small  muslin  bags  filled  with  phenolized  or  boracic  cotton-wool. 
An  india-rubber  bag  filled  with  hot  water  should  be  ready  for  use  ; 
a  flannel  belt  to  pin  round  the  body,  and  some  large  safety  pins 
to  fasten  it.  Some  brandy,  one  or  two  pint  bottles  of  cham- 
pagne,  and   some    ice,    must  be  entrusted  to  her  care  ;  and 


272  TEMPERATURE    OF   ROOM 

a  small  enema  bottle,  holding  an  ounce,  with  an  elastic 
tube,  a  minim  measure  and  some  laudanum  should  be  pro- 
vided, so  that  in  case  of  pain  a  dose  of  it  may  be  injected  into 
the  rectum.  A  feeding-cup  is  also  wanted,  so  that  barley-water, 
beef-tea,  soda-water,  with  or  without  milk,  may  be  given  with- 
out the  patient  rising. 

The  temperature  of  the  room  need  not  be  so  high  as  was 
formerly  supposed  indispensable,  nor  need  any  attempt  be  made 
to  charge  the  atmosphere  with  moisture.  In  the  first  paper  on 
five  cases  of  ovariotomy  which  I  brought  before  the  Medical 
and  Chirurgical  Society,  I  already  expressed  my  belief  that 
many  of  the  symptoms,  supposed  to  be  caused  by  the  operation, 
were  in  reality  due  to  the  confinement  of  the  patient  in  a  hot, 
close  room  filled  with  watery  vapour,  and  showed  that  both 
patient  and  surgeon  were  very  much  more  comfortable  in  an 
ordinary  atmosphere.  Perhaps  the  temperature  of  the  room 
should  not  be  below  65°  Fahrenheit,  but  it  need  not  be  raised 
to  an  uncomfortable  degree  above  this  point.  The  patient 
should  wear  her  ordinary  night-dress,  warm  woollen  stockings, 
and  a  loose,  short  flannel  dressing-jacket.  Anything  tight 
round  the  neck  or  body  should  be  removed.  Even  if  the 
bowels  have  acted  on  the  morning  of  the  day  selected  for 
operation,  the  rectum  should  be  thoroughly  cleared  out  by  an 
injection  of  warm  water.  She  should  not  eat  anything  for  four 
hours  before  the  anaesthetic  is  administered,  and  a  little  good 
beef-tea,  with  dry  toast,  will  be  enough  for  the  morning  meal. 
I  find  about  two  or  three  in  the  afternoon  a  better  time  for 
operating  than  an  early  morning  hour.  A  patient  who  expects 
to  undergo  an  operation  early  in  the  morning  seldom  sleeps 
well,  or  she  awakes  wearied  and  depressed  ;  but  if  she  is  to  get  up 
to  breakfast,  and  does  not  expect  her  fate  to  be  decided  till  the 
afternoon,  she  sleeps  better,  and  there  is  time  for  clearing  the 
bowels  after  breakfast.  If  she  has  had  a  warm  bath  the  night 
before,  her  skin  is  in  a  better  state  for  perspiring,  and  the 
abdomen  should  be  thoroughly  cleansed  by  soap  and  water.  It 
is  always  well  to  know  the  morning  and  evening  temperature  of 
a  patient  two  or  three  days  before  operation,  and  it  is  very 
important  that  the  nurse  should  be  properly  instructed  in  the 
use  of  the  clinical  registering  thermometer. 

Tables  on  which  the  patient  is  to  lie  for  the  operation,  and 


ARRANGEMENT    OF    PATIENT    FOR   OPERATION  273 

another  table  for  the  instruments,  should  be  placed  opposite  a 
window  admitting  a  good  light,  with  foot-pans  or  pails  beneath 
for  the  reception  of  the  fluid.  The  nurse  should  have  a  good 
fire  in  the  room,  a  plentiful  supply  of  hot  and  cold  water,  and 
ought  to  see  that  everything  is  in  such  readiness  that,  after  the 
patient  is  in  the  room,  it  may  not  be  necessary  to  send  for  any- 
thing, or  to  open  the  door.  With  some  few  unusually  nervous 
patients  it  may  be  desirable  to  administer  the  anaesthetic  in  an- 
other room,  or  in  bed  in  the  same  room,  before  she  is  placed  on 
the  table ;  but,  as  a  rule,  as  soon  as  they  have  emptied  the  blad- 
der, patients  may  generally  walk  to  the  table  and  arrange  them- 
selves upon  it,  with  some  little  assistance,  in  the  position  desired 
by  the  surgeon.  The  night-gown  should  be  pressed  up  towards 
the  shoulders.  In  order  to  have  as  few  assistants  as  possible, 
a  broad  strap  should  be  carried  over  the  patient's  knees,  and 
around  the  table,  and  tightly  fastened.  The  hands  should  also 
be  securely  fixed  by  a  bandage  to  a  leg  of  the  table  on  each 
side.  The  head  should  be  laid  in  a  comfortable  position  on 
pillows ;  and,  except  the  abdomen  and  face,  the  whole  body 
should  be  covered  with  warm,  light  blankets  or  flannel.  The 
abdomen  should  be  covered  by  a  waterproof  sheet,  with  an 
opening  about  eight  inches  long  and  six  inches  wide  in  the 
middle ;  the  inner  surface  spread  with  a  coating  of  adhesive 
plaster  of  about  an  inch  in  width  all  round  the  opening,  so  that  it 
may  adhere  to  the  skin,  and  prevent  any  exposure  of  the  patient, 
while  her  body  and  clothing  are  kept  perfectly  dry  and  clean. 

The  next  drawing  shows  how  I  am  now  in  the  habit  of 
arranging  two  ordinary  tables  near  the  window,  with  the  patient 
covered  upon  them ;  the  table  for  the  instruments  being  to  the 
right  hand  of  the  operator,  and  the  steam  spray  apparatus  near 
the  feet  of  the  patient  to  her  left  placed  upon  another  table — 
always  supposing  the  surgeon  uses  the  spray. 

The  necessary  instruments  for  a  simple  case  of  ovariotomy 
are  extremely  few :  a  scalpel,  to  divide  the  abdominal  wall ;  a 
director,  to  protect  the  cyst  as  this  division  is  completed ;  a 
trocar,  to  empty  the  cyst ;  needles  and  silk,  to  secure  the 
pedicle  and  close  the  wound  ;  with  forceps  and  ligatures,  to 
secure  any  bleeding  vessels,  complete  the  list.  But  there  is, 
perhaps,  no  surgical  operation  where  the  surgeon  may  be  so 
met  by  difficulties  where  he  least  expected  them,  and  it  so 

T 


274  ARRANGEMENT   OF   PATIENT   FOR   OPERATION 


INSTRUMENTS    FOR   OVARIOTOMY  275 

often  happens  that  instruments  are  wanted  which  would  not 
be  at  hand  if  only  the  instruments  required  for  an  ordinary 
case  were  taken,  that  it  is  a  safe  rule  to  take  to  every  case  a 
full  supply  of  instruments,  to  meet  every  possible  emergency. 
Cautery  clamps  and  cauteries  for  cases  where  the  cautery  is 
applicable,  ligatures  and  needles  of  different  shapes  and  sizes 
for  cases  where  neither  clamp  nor  cautery  is  used,  pressure 
forceps  for  temporarily  securing  separated  omentum  or  torn 
vascular  adhesions,  and  for  securing  arteries  by  ligature  or 
torsion,  vulsella  specially  adapted  for  holding  large  cysts,  a 
chain  and  wire  ecraseur,  drainage  tubes  of  glass,  vulcanite,  or 
india-rubber,  and  perchloride  of  iron  should  always  accompany 
the  surgeon.  Only  the  instruments  which  the  operator  thinks 
likely  to  be  required  need  to  be  arranged  on  the  table  to  his 
right ;  all  others  in  reserve  should  be  placed  ready  for  use  in  a 
drawer,  or  on  a  tray,  out  of  the  way,  but  close  at  hand.  All 
this  having  been  done,  and  the  table  with  the  instruments 
covered  with  a  towel,  the  light  subdued,  and  no  other  person 
present  than  the  operator,  the  administrator  of  the  anaesthetic 
and  the  nurse,  the  patient  may  be  brought  into  the  room. 

Before  proceeding  to  describe  the  various  steps  of  the 
operation,  a  few  lines  may  be  given  to  the  consideration  of  the 
anaesthetic,  and  to  an  account  of  the  most  important  instru- 
ments which  I  use. 

In  all  my  earlier  operations  chloroform  was  the  anaesthetic 
given.  Vomiting  following  the  operation  so  speedily,  and 
continuing,  just  as  after  other  operations,  with  the  distressing 
persistency  known  as  '  chloroform  sickness,'  was  very  frequently 
observed,  in  some  cases  led  to  great  danger,  and  even  became  a 
principal  cause  of  fatal  results.  I  tried  sulphuric  ether ;  but 
the  large  quantity  necessary,  the  diffusion  of  the  vapour 
throughout  the  room,  the  irritating  cough  it  produced,  and  the 
difficulty  of  inducing  complete  anaesthesia  by  it,  induced  me  to 
search  for  a  better  anaesthetic.  I  tried  a  mixture  of  chloroform 
and  ether  in  different  proportions,  but  soon  became  aware  that 
the  patient  was  at  first  only  affected  by  the  lighter  vapour  of 
the  ether,  and  was  then  subjected  to  the  action  of  chloro- 
form just  as  she  was  least  able  to  bear  it.  The  addition 
of  alcohol  to  the  ether  and  chloroform  made  a  mixture  which 
given  by   Mr.  Robert  Ellis   with  the  apparatus   he   devised 

T    2 


276  METHYLENE 

appeared  to  answer  better;  and  I  was  trying  this  triple  com- 
bination when  Dr.  Eichardson  brought  his  experiments  with 
the  bichloride  of  methylene  before  the  profession. 

An  impression  has  prevailed  that,  while  bichloride  of  methy- 
lene may  be  usefully  employed  in  operations  on  the  eyes,  it  is 
not  an  agent  of  very  extensive  utility,  nor  likely  to  supersede 
the  use  of  chloroform  in  general  surgery.  And  I  have  seen 
and  heard  several  statements  to  the  effect  that,  like  nitrous 
oxide  gas,  the  bichloride  of  methylene — or  chloromethyl,  as  it 
may  be  more  conveniently  called — is  only  useful  for  short 
operations,  and  that  it  cannot  be  safely  administered  for  more 
than  one  or  two  minutes.  But  as  my  experience  would  show 
that  this  commonly  expressed  opinion  is  the  very  reverse  of  the 
truth,  it  seems  to  be  my  duty  to  make  known  what  I  have 
seen  of  the  use  of  chloromethyl  in  general  surgery. 

The  first  surgical  operation  in  which  chloromethyl  was  ever 
used  was  a  case  of  ovariotomy,  which  I  performed  in  October 
1867.  It  was  administered  by  Dr.  Eichardson  himself;  and  in 
his  report  to  the  British  Association  in  1868,  he  says:  'After 
subjecting  myself  to  the  action  of  the  vapour  to  the  production 
of  perfect  insensibility,  I  ventured  to  administer  it  for  surgical 
purposes  on  October  15  last.  The  sleep  produced  was  of  the 
simplest  and  gentlest  character,  and  the  operation  performed 
by  Mr.  Spencer  Wells,  which  lasted  thirty-five  minutes,  was 
quite  painless.' 

This  was  my  229th  case  of  ovariotomy.  I  have  now  done 
ovariotomy  more  than  one  thousand  and  sixty  times  ;  and,  with 
the  exception  of  about  ten,  where,  for  some  reason  or  other, 
chloroform  was  used,  chloromethyl  was  the  anaesthetic  employed 
in  every  case,  about  840  in  number.  In  some  100  other  cases 
of  gastrotomy,  and  in  more  than  300  operations  of  more  or  less 
severity — such  as  herniotomy,  amputation  of  the  breast,  removal 
of  mammary  or  other  tumours,  or  of  hemorrhoids,  and  plastic 
operations  for  the  cure  of  vaginal  fistula  or  ruptured  perineum 
— chloromethyl  has  been  administered  for  me,  either  by  Dr. 
Eichardson  himself  or  by  my  colleagues,  Dr.  Junker  and  Dr. 
Day.  In  very  few  of  these  operations  was  the  condition  of 
insensibility  to  pain  maintained  for  less  than  five  minutes.  In 
a  few,  it  was  kept  up  from  forty-five  minutes  to  an  hour  or 
more ;  and  I  should  think  the  average  would  be  about  fifteen 


MODIFICATION   OF   THE   SYPHON   TROCAR  277 

minutes.  Yet  I  have  never  been  at  all  uneasy  in  any  one  of 
these  cases,  about  1,500  in  number,  either  during  the  adminis- 
tration of  the  anaesthetic  or  from  any  subsequent  ill-effects 
fairly  referable  to  it.  Whereas,  with  chloroform  I  never  felt 
quite  at  ease ;  and,  although  I  never  lost  a  patient  during 
operation,  I  have  three  times  had  to  resort  to  artificial  respira- 
tion, and  I  have  very  often  seen  patients  suffer  so  much  from 
chloroform-vomiting  for  many  hours  after  operation,  that  the 
result  has  been  imperilled.  And  in  some  cases  death  has  been  in  a 
great  measure  due  to  the  vomiting.  It  is  quite  true  that  chloro- 
methyl  is  not  quite  free  from  'the  disadvantage  of  causing  nausea 
and  occasional  sickness; '  but, in  my  experience,  this  is  almost  the 
rule  with  chloroform,  whereas  with  chloromethyl  it  is  certainly 
exceptional.  I  think  after  this  evidence  it  must  be  admitted  (as 
anaesthesia  was  complete  in  every  case,  not  one  patient  having 
been  conscious  at  any  stage  of  the  operation)  that  the  anaesthetic 
employed  is  a  good  one.  In  some  cases  less  than  two  drachms 
was  used,  and  very  rarely  more  than  six  drachms.  Dr.  Junker's 
apparatus  was  generally  employed ;  and  Mr.  Krohne  tells  me 
that  many  practitioners  on  the  Continent,  in  America,  and  in 
different  parts  of  our  own  country,  who  have  ordered  it  from 
him  after  seeing  it  in  my  practice,  have  used  it  without  diffi- 
culty, and  have  been  well  pleased  with  the  results.  A  patient 
may  be  kept  in  a  state  of  perfect  unconsciousness  throughout 
a  prolonged  operation  with  methylene  administered  by  the 
apparatus  devised  by  Dr.  Junker.  Scarcely  any  of  the  vapour 
escapes  into  the  room ;  neither  the  surgeon  nor  the  assistants 
are  affected  by  it ;  a  patient  very  seldom  becomes  pale,  she 
sleeps  quietly,  awakes  quietly,  is  not  often  sick,  and  seldom  has 
much  bronchia]  irritation  referable  to  the  chloromethyl.  Indeed, 
she  gains  all  the  advantages  of  complete  anaesthesia  with  fewer 
drawbacks  than  by  the  use  of  any  other  anaesthetic. 

The  trocar  used  in  ovariotomy  by  all  the  earlier  operators 
was  an  ordinary  trocar  of  full  size.  When  Mr.  Thompson's 
instrument  came  into  use  for  ordinary  tapping,  I  had  one  en- 
larged and  lengthened  for  ovariotomy  ;  and  when  I  had  learned 
the  advantages  of  the  syphon  trocar,  which  has  been  described 
in  the  chapter  on  Tapping,  I  also  enlarged  this  for  use  in 
ovariotomy.  Then,  finding  that  the  cyst  was  apt  to  slip  off  the 
trocar,  or  that  the  fluid  would  escape  between  the  perforation 


278  SYPHON  TROCAR  FOR  OVARIOTOMY 

in  the  cyst  and  the  canula,  I  had  roughened  rings  adapted  to 
the  canula,  so  that  the  cyst  might  be  securely  tied,  fixing  it  to 
the  canula,  preventing  the  escape  of  fluid,  and  serving  as  an 
aid  in  drawing  out  the  cyst.  This  occupying  too  much  time, 
I  had  two  spring  handles,  each  furnished  with  a  series  of  hooks, 
adjusted  outside  the  canula,  by  which  the  emptying  cyst  could 
be  immediately  fastened  to  the  canula ;  and  this  instrument, 
now  sufficiently  well  known  and  described  as  my  ovariotomy 
trocar,  I  have  used  for  several  years  past,  and  have  been  well 
satisfied  with  it. 

In  1871,  Dr.  Fitch,  of  Portland,  in  the  United  States, 
showed  me  a  modification  of  the  instrument,  which  appears  to 
be  an  improvement.  Instead  of  the  inner  tube  having  a 
cutting  point,  which  for  protection  is  withdrawn  into  the  outer 
tube  or  canula,  as  soon  as  the  cyst  has  been  perforated,  Dr. 
Fitch  made  the  outer  tube  cutting,  and  protected  it  by  pushing 
the  inner  tube  forward.  He  also  lengthened  and  curved  the 
end  of  the  canula  upon  which  the  tube  is  fixed,  with  the  object 
of  gaining  a  sort  of  pistol  handle,  rendering  the  instrument 
more  manageable,  and  enabling  us  to  use  an  ordinary  india- 
rubber  tube,  without  fear  of  stopping  the  current  by  its  bending. 
This  instrument  is  very  well  made  by  Krohne.  Whether  my 
old  ovariotomy  trocar  or  the  instrument  with  this  modification 
of  Dr.  Fitch's  be  used,  a  cyst  is  punctured,  when  partly  empty 
is  fixed  on  to  the  canula  by  the  spring  hooks,  so  that  trocar, 
ligature,  and  vulsellum  are  united  in  one  instrument,  and  a 
large  cyst  may  be  rapidly  emptied  and  readily  withdrawn,  with- 
out any  fear  of  its  contents  escaping  either  into  the  abdominal 
cavity  or  about  the  patient. 


As  aids  to  the  hooked  trocar  in   drawing  out  a  cyst,  or  in 
holding  a  cyst  which  has  been  opened  outside  the  abdominal 


CAUTEEY   CLAMP  279 

cavity,  while  the  septa  of  inner  cysts  are  being  broken  up  and 
the  contents  brought  out,  hooked  forceps,  or  vulsella  of  different 
kinds,  are  often  necessary.  The  best  of  these  instruments  is 
that  sold  by  many  makers,  and  known  as  Nelaton's  vulsellum. 
It  holds  the  cyst  very  securely,  does  not  slip  nor  tear  the  cyst. 
The  essential  or  grasping  part  of  the  instrument  is  shown 
in  the  last  drawing. 

The  clamp  which  is  used  for  temporary  compression  of  the 
pedicle  when  we  intend  to  trust  to  the  cautery  for  stopping 
bleeding  from  the  divided  vessels  of  the  pedicle,  is  known  as 
the  Cautery  Clamp.  The  original  instrument  was  devised  by 
Mr.  Clay,  of  Birmingham,  in  order  to  stop  bleeding  from  vessels 
in  the  omentum,  which  had  been  adherent  to  and  separated  from 
the  cyst.  It  is  to  him  we  are  indebted  for  the  principle  of 
combining  compression  and  cauterization  in  the  suppression  of 
haemorrhage.  The  cautery  clamp  not  only  securely  holds  the 
pedicle,  but  so  firmly  compresses  the  portion  included  within 
the  blades,  that  alone  it  would  be  almost  sufficient  to  control 
the  bleeding  from  any  vessels  not  large ;  but  when  the  divided 
edge  of  the  pedicle  is  seared  by  the  actual  cautery,  the  effect 
of  compression  is  assisted  by  the  line  of  eschar  or  plugging 
formed  at  the  cauterized  part ;  and  the  blades  of  the  clamp 
being  necessarily  heated  during  the  application  of  the  cautery, 
the  compressed  part  of  the  pedicle  is  also  heated,  the  blood  in 
its  vessels  is  coagulated,  and  when  the  clamp  is  removed,  if  this 
has  been  done  carefully,  and  the  compressed  and  heated  tissues 
are  not  disturbed,  a  thin  band  almost  like  wash-leather,  with 
the  seared  edge,  becomes  a  very  efficient  safeguard  against 
bleeding.  Soon  after  Mr.  Clay  described  the  successful  appli- 
cation of  his  cautery  clamp  in  suppressing  bleeding  from  torn 
adhesions  and  separated  omentum,  Mr.  Baker  Brown  was  the 
first  to  apply  it  to  the  pedicle.  He  improved  the  instrument 
by  making  it  broader,  by  adding  a  guard  to  prevent  slipping  of 
the  cautery,  and  an  ivory  shield  to  protect  the  soft  parts  from 
the  action  of  the  heated  clamp.  His  results  were  so  successful 
that  I  tried  the  method ;  and,  after  a  case  or  two,  curved  the 
handles,  altered  the  joint,  substituted  a  better  non-conductor 
for  ivory,  and  used  the  galvanic  cautery  and  the  gas  cautery, 
instead  of  the  common  irons.  The  only  improvement  upon 
this   instrument   which   I  have  seen  is  one  by  the   late  Dr. 


280 


CAUTERIZING    IRONS 


Skoldberg,  of  Stockholm,  which  makes  the  action  of  the  blades 
more  parallel.  Pratt  carried  out  the  same  idea  for  me  many 
years  ago,  and  Dr.  Braxton  Hicks  had  also  contrived  a  parallel 
bladed  cautery  clamp,  which  I  used  with  fair  success ;  but  Dr. 
Keith,  after  many  trials,  found  the  original  instrument  of  Baker 
Brown  to  be  the  best. 

The  cauterizing  irons  used  by  Mr.  Baker  Brown  were  the 
ordinary  conical  irons,  with  a  sharp  edge,  used  in  firing  joints. 


With  these  instruments  made  red  hot  in  the  fire,  he  divided  the 
pedicle,  as  shown  in  this  cut,  the  tumour  being  held  up  by  an 
assistant.  This  was  a  tedious  and  troublesome  process  ;  and  I 
found  that  the  same  end  was  attained  by  cutting  away  the  cyst 
half  an  inch  or  so  from  the  clamp,  and  then  burning  away  all 
the  tissue  that  projected  beyond  the  surface  of  the  clamp.  Flat 
irons  answered  this  purpose  better  than  the  conical  ones  ;  and 
nothing  answers  better  than  the  common  spatulas  used  by 
druggists  in  spreading  plasters.  The  galvanic  cautery  answers 
equally  well,  and,  when  it  is  inconvenient  to  have  a  fire  in  the 
room,  would  be  generally  preferred,  if  it  were  possible  always 
to  secure  efficient  battery  action  ;  but  as  this  is  uncertain,  the 


THE   £CRASEUR  281 

gas  cautery  of  Nelaton,  either  simple,  or  with  the  addition  of 
the  blow-pipe  and  the  platinum  capsules  devised  by  the  late 
Mr.  Alexander  Bruce,  answers  equally  well ;  and  Meyer  once 
made  for  me  a  platinum  cautery,  with  a  spirit  lamp  to  heat  it, 
which  was  also  as  satisfactory  in  its  action  as  the  hot  irons. 
Since  the  introduction  of  Paquelin's  cautery,  this  has  been 
generally  employed,  but  Dr.  Keith  adheres  to  the  original  form 
of  conical  iron  heated  in  the  fire.  I  believe  it  is  of  very  little 
consequence  which  of  the  cauteries  is  used,  provided  the  clamp 
exerts  sufficient  compressing  force,  and  time  is  taken  to  caute- 
rize slowly,  so  that  the  pedicle  is  subjected  to  the  somewhat 
prolonged  influence  of  heat. 

The  ordinary  chain  ecraseur  has  been  used  several  times 
successfully  in  dividing  the  pedicle.  I  believe  I  was  the  first 
to  adopt  this  practice,  but  although  the  case  proved  successful, 
I  was  so  fearful  of  secondary  bleeding  that  I  have  never  repeated 
the  experiment.  When  the  ecraseur  is  used,  not  to  divide  the 
pedicle  but  simply  to  secure  it  as  a  kind  of  clamp,  the  chain 
with  a  nut  and  screw  is  made  so  that  it  can  be  removed  from 
the  handles  and  left  upon  the  abdomen  just  like  a  clamp.  I 
once  tried  wire-rope  in  this  way,  instead  of  a  chain,  but  found 
it  so  difficult  to  fasten  it  tight  enough  without  cutting  that  I 
gave  up  its  use  altogether. 

In  Chapter  I.  some  remarks  may  be  found  upon  the  rota- 
tion of  ovarian  tumours  and  the  twisting  of  the  pedicle,  and  I 
have  already  alluded  to  cases  which  have  occurred  in  my  own 
practice  where,  long  before  the  operation,  the  pedicle  had  given 
way  and  the  cyst  had  received  its  whole  blood  supply  through 
omental  vessels.  There  can  be  no  question,  therefore,  as  to  the 
feasibility  of  tearing  through  a  pedicle,  or  of  twisting  off  an 
ovarian  tumour.  Maisonneuve  was  the  first  actually  to  practise 
this  twisting  in  ovariotomy ;  he  twisted  the  cyst  round  and 
round  until  the  pedicle  gave  way.  Macleod,  of  Glasgow,  has 
improved  upon  this  practice,  and  Hilliard,  the  Glasgow  surgical 
instrument  maker,  has  modified  some  of  the  instruments  used 
by  veterinary  surgeons  in  castration,  in  order  to  hold  the 
pedicle  securely  with  one  hand  while  the  cyst  is  held  and 
twisted  with  the  other.  Macleod  has  had  one  successful  case, 
and  his  example  has  been  followed  with  good  results  in  Leeds. 
[t  is  possible  that  there  may  be  cases  where  this  method  may 


282  FORCEPS 

be  preferable  to  the  ligature  or  the  cautery,  but  I  can  say 
nothing  on  this  point  from  personal  experience. 

As  it  is  never  improbable,  by  whatever  intra-peritoneal 
method  the  pedicle  may  have  been  secured,  that  bleeding 
vessels  low  down  in  the  pelvis  may  have  to  be  found  and 
secured  where,  the  patient  lying  opposite  the  light,  the  pelvis 
is  necessarily  in  deep  shadow,  the  surgeon  should  always  be 
provided  with  a  hand  mirror  to  reflect  light  to  the  bottom  of 
the  pelvis.  On  a  clear  day  this  gives  quite  light  enough,  but 
in  any  foggy,  dark,  or  cloudy  weather,  or  when  operating  late 
in  the  day,  a  candle  lamp,  with  a  reflecting  concave  mirror, 
often  becomes  very  serviceable.  ^Collin's  lamp  is  handy,  but 
too  small.  A  policeman's  '  bull's-eye,'  or  a  good  carriage  lamp, 
is  generally  to  be  had,  and  it  is  to  be  hoped  that  by  Faure's 
storage  battery  a  good  reflected  electric  light  may  be  con- 
veniently obtained. 

With  regard  to  the  other  instruments,  it  can  only  be  neces- 
sary to  repeat,  that  the  surgeon  should  be  prepared  with 
scalpels,  a  probe-pointed  bistoury,  a  broad  Key's  director,  fine 
strong  pure  ligature  silk,  straight  needles,  forceps,  and  scissors. 

The  forceps  most  useful  as  temporary  suppressors  of 
haemorrhage  are  those  sold  as  my  torsion  or  pressure  forceps. 
The  ordinary  '  bull-dogs '  are  too  small,  and,  if  used,  should 
have  a  long  piece  of  wire  or  silk  attached  to  them  as  a  safe- 
guard against  their  accidental  entry  into  the  peritoneal  cavity  ; 
but  I  have  for  many  years  used  forceps  with  long  handles,  which 
answer  all  the  purposes  of  '  bull-dogs,'  as  well  as  of  artery  and 
torsion  forceps.  Mathieu's  catch  at  the  handles  serves  instan- 
taneously to  fix  the  instrument,  and  the  short,  roughened  points 
hold  a  vessel  very  securely,  stop  bleeding  completely,  and  enable 
the  surgeon  to  twist  the  vessel  if  he  wishes.  These  forceps  are 
well  made  by  Krohne  and  Hawksley. 

The  forceps  of  Pean,  as  well  as  Koeberle's,  may  be  either 
curved  or  angular.  But  they  all,  like  Koeberle's,  have  the  great 
disadvantage  of  an  open  space  between  the  blades,  which  admits 
of  entanglement  of  one  instrument  with  another,  or  of  the 
passage  of  omentum  or  other  structures.  This  was  a  fault  in 
my  own  earlier  instruments.  It  has  been  completely  corrected 
in  the  later  instruments  made  for  me  by  Mr.  Hawksley,  without 
at  all  lessening  the  compressing  power  exerted  on  the  vessel. 


PRESSURE-FORCEPS 


283 


In  October  1878  Mr.  Hawksley  carefully  tested  the  com- 
pressing power  of  different  forceps  when  opened  by  a  piece  of 
leather  one  millimetre  thick  between  the  jaws  of  the  forceps, 
and  covering  about  four  teeth  from  the  points.  The  following 
table  gives  the  result : — 

Pounds  avoirdupois  exerted  oy  four  teeth  of  the  end  of  forceps  when  one 
millimetre  apart. 

First  catch 


Forceps 
Koeberle 
Pean 

S.  Wells  (old) 
„       (new) 


8 
18 
5-7 


Second  catch 

si 

12 
15-17 


It  may  be  seen  that  in  my  old  instrument  there  is  only  one 
catch,  and  in  my  new   one,  the  second  catch  only  exerts  the 


same  power  as  the  first  catch  of  the  old  instrument.  But  this 
is  five  times  greater  than  the  second  catch  in  Koeberle's,  and 
one-third  more  than  that  of  Pean's.  When  only  the  first  catch 
in  Koeberle's  instrument  is  closed,  the  points  are  separated 
about  half  a  centimetre,  so  that  they  only  compress  anything 
more  than  that  thickness.  I  have  used  all  these  instruments, 
but  find  them  much  less  handy  than  my  own,  in  which  the 
handles  meet  without  leaving  any  opening  between  them. 
The  rings  do  not  admit  the  thumb  and  finger  too  far ;  and  the 
end  which  compresses  the  vessel  is  so  bevelled,  that,  if  it  be 
desirable  to  apply  a  ligature,  the  silk  will  easily  slip  over  the 
forceps,  and  not  tie  them  together.  Thus  my  instrument  is 
not  only  useful  in  forcipressure  and  in  torsion,  but  enables  the 
surgeon  to  dispense  with  any  other  kind  of  artery-forceps  if 
he  wish  to  apply  a  ligature. 


284 


LARGE   PRESSURE-FORCEPS 


The  distal  end  of  the  larger  forceps  made  upon  the  same 
principle  which  I  use  for  holding  the  pedicle  in  ovariotomy,  or 


any  mass  of  tissue  in  other  operations  where  the  temporary 
command  of  bleeding  or  oozing  vessels  is  urgent,  is  here 
represented  of  its  ordinary  size  ;  and  the  pressure  in  use  is 
ascertained  to  be  in  pounds  avoirdupois  : — 

Large  forceps— 1^  in.  fulcrum — object  1  millimetre  : — 


First  catch 
20-10 


Second  catch 
32-8 


Third  catch 
47-8 


Fourth  catch 
60-0 


All  these  instruments  are  placed  on  a  table  near  the  feet  of 
the  patient  and  the  right  hand  of  the  operator,  in  shallow 
dishes,  or  soup  plates,  filled  with  a  2  per  cent,  solution  of 
phenol.  The  smaller  forceps  are  more  conveniently  arranged  in 
upright  trays,  to  which  they  are  returned  immediately  after  use, 
and  must  be  carefully  counted  before  the  abdomen  is  closed. 


INCISION   OF   THE   ABDOMINAL  WALL  285 


CHAPTEK  VIII. 

THE  OPERATION  OF  OVARIOTOMY  ;  DIVISION  OF  THE  ABDOMINAL 
WALL  ;  SITUATION  AND  LENGTH  OF  INCISION ;  SEPARATION 
OF  THE   CYST  ;   EMPTYING  AND   REMOVAL. 

We  shall  now  suppose  that  the  instruments  have  all  been 
placed  where  the  surgeon  can  reach  them  without  moving  from 
his  post ;  that  the  patient  has  been  placed  on  the  table,  secured 
there  by  the  thigh  strap  and  the  wristbands,  covered  by  the 
adhesive  waterproof  sheet,  and  brought  under  the  complete 
influence  of  the  anaesthetic.  The  surgeon,  standing  on  the 
right  side  of  the  patient,  with  his  right  hand  towards  the  light, 
has  one  assistant  on  his  left  hand,  and  another  facing  him  on 
the  left  of  the  patient.  Nurses,  with  sponges  and  the  different 
necessary  articles  already  enumerated,  are  also  behind  and  to 
the  left  of  the  patient,  while  the  administrator  of  the  ansesthetic 
stands  at  her  head.  All  is  now  ready  for  the  first  step  of  the 
operation,  namely — 

THE   INCISION   OF  THE  ABDOMINAL   WALL. 

We  have  now  to  consider  the  situation  and  length  of  the 
incision. 

In  all  my  cases  the  linea  alba  has  been  selected  as  the  seat  of 
incision  (as  shown  on  the  next  page),  and  in  a  very  large  majority 
of  the  cases  on  record  other  operators  have  selected  the  same 
situation.  But  in  some  few  cases  the  incision  has  been  inten- 
tionally carried  either  to  the  right  or  left  of  this  line.  One  of 
the  linese  semilunares  has  been  occasionally,  though  very  rarely, 
selected  ;  and  in  some  few  exceptional  cases  oblique  or  trans- 
verse incisions  have  been  made.  Thus  Dr.  Atlee  in  one 
successful  case  made  an  incision  seventeen  inches  long,  from 
the  symphysis  pubis  to  the  middle  of  the  crest  of  the  right 
ilium.     Buhring  made  an  incision  at  the  outer  border  of  the 


286 


EARLY   PRACTICE 


external  oblique  on  the  right  side  from  the  false  ribs  to  the 
crest  of  the  ilium. 

In  one  of  the   earliest  cases  in  England,  Mr.  King  made 


one  vertical  incision,  seven  or  eight  inches  long,  to  the  right 
of  the  umbilicus,  and  another  four  inches  long  at  right  angles, 
extending  towards  the  spine.  In  this  case  no  tumour  could 
be  found,  and  the  patient  recovered.  In  another  case  he  made 
'  a  division  of  about  three  inches  through  the  integument  and 
the  linea  semilunaris  of  the  left  side,  a  little  above  a  line 
drawn  across  the  abdomen  from  the  umbilicus.' 

An  incision  nine  inches  long  was  made  by  Dr.  Mercier, 
from  the  '  lower  ribs  to  external  edge  of  rectus  muscle.' 

Dr.  Haartmann  made  an  incision,  five  inches  long,  parallel 
with  Poupart's  ligament ;  and  Dr.  Dorsey  made  a  vertical  in- 
cision eight  inches  long,  by  a  transverse  incision  in  the  left 
side  six  inches  long.  These  are  the  principal  examples  on 
record  of  oblique  or  transverse  incisions.  Vertical  incisions  to 
one  or  other  side  of  the  linea  alba  have  been  less  uncommon. 

Dr.  McDowell,  in  his  first  and  second  cases,  made  his  in- 
cisions nine  inches  long,  three  inches  from  and  parallel  to  the 
left  rectus.  In  his  subsequent  cases  he  seems  to  have  selected 
the  linea  alba. 

Some  writers,  as  Hamilton,  who  describes  his  incision  as 
'  corresponding  to  the  inner  margin  of  the  right  rectus,'  merely 


STRUCTURE   OF  THE   LINE  A   ALBA  287 

express  in  other  words  division  of  the  linea  alba.  The  object 
is  to  avoid  either  of  the  recti  muscles.  The  only  operator,  so 
far  as  I  know,  who  prefers  division  of  one  of  the  muscles,  is 
Dr.  Storer,  of  Boston,  who  says,  '  I  differ  from  most  operators 
in  that  I  prefer  making  the  section  in  the  track  of  a  rectus 
muscle  rather  than  in  the  linea  alba,  being  thus  much  more 
certain,  from  the  nature  of  the  tissue  divided,  of  a  primary 
reunion.' 

As  I  do  not  believe  it  possible  that  a  divided  and  reunited 
muscle,  even  when  most  complete  union  results,  can  form  so 
firm,  unyielding,  and  perfect  a  portion  of  the  abdominal  wall 
as  the  uninjured  muscle  in  its  normal  state — as  I  do  not  think 
that  division  of  the  muscle  can  make  union  of  the  skin,  peri- 
toneum, or  cellular  tissue  more  certain  or  complete — and  as  I 
never  once  saw  any  want  of  union  when  the  recti  had  been 
carefully  avoided,  I  always  endeavour  to  divide  the  linea  alba 
accurately,  without  opening  the  sheath  of  either  rectus. 

It  is  not  often  easy  to  do  this,  for  the  weight  of  the  tumour 
has  generally  either  drawn  the  recti  to  one  side,  or  the  muscles 
have  been  spread  out  over  the  anterior  surface  of  the  cyst. 
Anatomically,  it  appears  a  matter  of  some  importance  not  to 
open  the  sheath  ;  but  although  it  is  well  to  try  to  hit  the  linea 
alba  exactly,  it  does  not  appear  of  much  importance  surgically 
if  one  edge  of  the  muscle  be  exposed,  or  if  a  division  be  made 
through  the  muscle  parallel  with  the  course  of  its  fibres.  If 
the  incision  be  extended  above  the  umbilicus,  it  is  better  to 
carry  it  round  to  the  left  side,  because  the  round  ligament  of 
the  liver  passes  diagonally  upwards  and  backwards  towards  the 
right  side,  and  might  be  wounded  if  the  incision  were  carried 
either  directly  through  the  umbilicus  or  to  the  right  side. 
In  some  cases  a  wound  of  the  round  ligament  might  not  be 
of  consequence,  but  in  others  it  might  lead  to  serious  haemor- 
rhage, as  the  embryonal  umbilical  vein  is  not  always  en- 
tirely obliterated,  but  remains  patent,  and  is  sometimes  of 
considerable  size. 

When  the  linea  alba  is  chosen  for  the  incision  the  following 
structures  are  successively  divided  : — 

1.  The  skin. 

2.  The  subcutaneous  areolar  tissue,  with  fat  of  varying 
thickness. 


288 


STRUCTURE    OF   THE   LINEA   ALBA 


3.  The  interlaced  fibres  of  the  aponeuroses  of  the  abdominal 
muscles  constituting  the  linea  alba. 

4.  Layers  of  the  fascia  transversalis  with  more  or  less 
fat.  The  uppermost  layer  adheres  closely  to  the  linea  alba. 
The  deepest  layer  is  only  very  loosely  connected  with  the 
peritoneum. 

5.  The  peritoneum. 

But  this  normal  arrangement  is  often  much  modified.  When 
there  is  much  oedema  of  the  abdominal  wall  the  different  layers 
may  be  widely  separated,  and  appear  as  if  increased  in  number, 
or  they  may  be  agglutinated  together  by  previous  inflammatory 
processes  ;  and,  as  before  mentioned,  the  recti  muscles  are  often 
carried  so  much  to  one  side  by  the  tumour  that  it  is  almost 
impossible  to  avoid  exposure  or  division  of  some  of  their  fibres. 

The  anatomical  question  may,  perhaps,  be  studied  by  the 
assistance  of  the  accompanying  diagrams,  which  show  the 
structures  necessarily  divided  if  the  abdominal  wall  be  cut 
through — 

1.  Along  the  linea  alba. 

2.  Through  one  of  the  recti  muscles,  and 

3.  Along  one  of  the  linese  semilunares. 

The  effect  of  division  in  the  upper  and  lower  part  of  the 
linea  alba  is  also  shown. 

Let  diagram  No.  1  represent  the  layers  just  enumerated 
as  divided,  when  an  incision  is  made  through  the  anterior 
abdominal  wall  at  the  linea  alba. 

No.  1. 


a.  Umbilicus. 

b.  Skin. 

c.  Linea  alba. 

d.  Symphysis. 

e.  Peritoneum. 


/.   Superficial  layer  of  areolar  tissue. 
g.  Deep  layer  of  areolar  tissue. 
h.  Areolar  tissue  rich  in  fat,  or  peri- 
mysium iDternum. 


PARTS   DIVIDED   IN   THE   DIFFERENT  INCISIONS 


289 


The  following  diagram  (No.  2)  will  then  show  how  many 
additional  layers  must  be  divided  if  the  incision  be  carried 
on  either  side  of  the  linea  alba  through  one  of  the  recti 
muscles. 

No.  2. 


a.  Umbilicus. 

b.  Skin. 

c.  The  rectus  muscle  with  its  inscrip- 

tiones  tendineas. 

d.  Symphysis  pubis. 

e.  Peritoneum. 

/.  Superficial  layer  of  areolar  tissue. 
g.  Deep  layer  of  areolar  tissue. 


h.  Perimysium  internum. 

i.  Aponeurosis    of    external   oblique 

muscle. 
k.  Aponeurosis    of    internal    oblique 

muscle. 
I.  Aponeurosis  of  transversalis  muscle. 
m.  Fascia  transversalis. 


The  diagram  No.  3  shows  the  layers  divided  if  the  incision 
be  made  along  one  of  the  linese  semilunares. 

No.  3. 


a.  Crest  of  the  ilium. 

b.  Skin. 

e.  Peritoneum. 

/.  Superficial  layer  of  areolar  tissue. 
g.  Fascia  superficialis. 
h.  Perimysium  internum. 


i.   Aponeurosis  of   external    oblique 

muscle. 
k.  Aponeurosis  of    internal    oblique 

muscle. 
I.  Aponeurosis  of    the   transversalis 

muscle. 
m.  Fascia  transversalis, 


290  PARTS    DIVIDED   IN   THE    DIFFERENT   INCISIONS 

Each  of  the  structures  which  make  up  the  anterior  ab- 
dominal wall,  and  are  arranged  in  the  layers  represented  in 
the  preceding  diagrams,  are  of  some  interest  to  the  surgeon 
who  performs  ovariotomy. 

1.  The  integument  is  thinner  and  more  sensitive  between 
the  sternum  and  the  umbilicus  than  in  other  regions.  Around 
the  umbilicus  it  is  not  movable,  being  firmly  connected  with 
the  aponeurotic  ring  by  cellular  tissue  which  contains  no  fat. 
But  when  fluid,  ovarian  or  ascitic,  is  free  in  the  peritoneal 
cavity,  it  often  passes  through  the  ring,  and  distends  the  integu- 
ments into  the  semblance  of  an  umbilical  hernia.  Below  the 
umbilicus  the  integument  is  very  often  found  cedematous,  and 
any  linese  albicantes  present  then  become  very  prominent ;  this 
condition  does  not  seem  to  interfere  with  union  of  the  incision 
by  first  intention. 

2.  The  subcutaneous  areolar  tissue  in  some  parts  of  the 
abdominal  wall  presents  two  distinct  and  separate  layers.  The 
superficial  layer  is  rich  in  fat-cells,  and  contains  the  superficial 
blood-vessels.  The  deeper  layer  has  more  the  character  of  a 
fibrous  fascia,  and  is  the  proper  fascia  superficialis.  This 
separation  is  most  apparent  in  the  hypogastric  and  inguinal 
regions,  and  is  more  easily  demonstrated  in  old  than  in  young 
persons.  Of  the  blood-vessels  which  ramify  in  the  cellular 
tissue,  only  the  external  epigastric  artery  and  vein  are  of  prac- 
tical interest.  The  artery,  or  some  of  its  larger  branches,  are 
more  likely  to  be  divided  when  the  incision  is  along  one  of  the 
linese  semilunares,  or  through  one  of  the  recti  muscles,  than 
when  the  linea  alba  is  divided.  But  it  can  be  readily  tied 
before  the  peritoneum  is  opened.  The  external  epigastric 
veins  are  frequently  enlarged  or  varicose  when  tumours  obstruct 
the  current  of  blood  along  the  inferior  vena  cava.  In  some 
rare  cases  a  subcutaneous  vein  communicates  through  the 
umbilical  ring  with  the  pervious  umbilical  vein.  A  slight 
deviation  in  the  line  of  incision  will  often  enable  the  surgeon 
to  avoid  enlarged  veins ;  and  if  this  cannot  be  done,  it  is 
advisable  to  stop  the  current  of  blood  through  the  vein  before 
it  is  divided,  by  pressure  forceps.  In  this  way,  what  might  be 
otherwise  a  serious  loss  of  blood,  is  prevented.  It  is  not  often 
necessary  to  use  a  ligature  after  the  forceps  are  removed. 

3.  The  sheaths  of  the  recti,  complete  anteriorly,  incomplete 


ANATOMICAL   DETAILS  291 

posteriorly  from  about  two  inches  below  the  umbilicus,  formed 
by  the  aponeuroses  of  the  fiat  abdominal  muscles,  and  terminat- 
ing in  the  linea  alba,  hardly  require  more  than  a  passing  men- 
tion. But  if  much  disturbed  during  the  first  incision,  abscess 
is  very  likely  to  delay  healing. 

4.  The  recti  and  pyramidales  muscles  are  almost  always 
seen,  and  one  or  other  may  or  may  not  be  divided  in  ovariotomy. 
When  the  recti  are  unusually  broad  near  the  pubes,  the 
pyramidales  may  be  absent.  When  the  recti  are  narrow 
below,  the  pyramidales  lying  in  front  of  the  recti,  and  inclosed 
in  the  sheath,  are  inserted  into  the  inner  border  of  the  sheath, 
half-way  between  the  pubes  and  the  umbilicus,  or  even  higher. 

5.  The  fibres  of  the  fiat  abdominal  muscles  cross  each  other 
in  different  directions,  embrace  the  recti  muscles,  and  conjoin 
on  the  linea  alba,  forming  a  tendinous  band,  which  is  very 
strong  at  the  pubic  end,  and  broader  and  weaker  at  the  sternal 
end.  The  fibres  of  the  aponeurosis  on  one  side  continue  across 
the  linea  alba,  and  interlace  with  fibres  coming  from  the 
opposite  side,  forming  meshes  which  in  the  normal  state  are 
very  small,  only  giving  passage  to  nerves  and  vessels ;  but 
which,  after  great  distension  of  the  abdominal  wall,  form 
apertures  through  which  small  masses  of  fat  may  escape  from 
beneath,  forming  what  have  been  called  Hernias  adiposae, 
and  often  leading  an  inexperienced  ovariotomist  to  think 
that  he  has  opened  the  peritoneal  cavity,  and  exposed  the 
omentum. 

6.  The  umbilicus  is  merely  one  of  these  openings  in  the 
linea  alba;  but  the  occasional  permeability  of  the  embryonal 
umbilical  vein  (already  referred  to)  must  be  borne  in  mind, 
and  the  fact  that  the  urachus  may  also  remain  permeable,  and 
urine  escape  from  the  bladder  through  it  at  the  umbilicus.  I 
have  never  seen  this  in  the  adult ;  but  in  one  case  of  ovariotomy 
I  found  the  urachus,  though  closed  at  both  ends,  open  for  the 
whole  length  of  my  incision  in  the  abdominal  wall,  and  filled 
by  small  urinary  concretions.  Usually  it  is  obliterated,  and 
forms  the  vesico-umbilical  ligament  running  up  along  the  linea 
alba  from  the  bladder  to  the  umbilicus. 

7.  The  deep  fascia,  or  the  layer  of  areolar  tissue  between 
the  inner  surface  of  the  transversalis  muscle  and  the  perito- 
neum, or  rather  between  the  fascia  transversalis  and  the  perito- 

D    2 


292  ANATOMICAL    DETAILS 

neum,  is  very  elastic,  and  only  loosely  adherent,  so  that  it  is 
easy  to  separate  the  peritoneum  to  a  considerable  extent  with- 
out opening  it.  Indeed,  if  fluid  be  free  in  the  peritoneal  cavity, 
the  membrane  bulges  up,  like  a  bluish  thin-walled  cyst,  as  soon 
as  the  deep  fascia  is  divided. 

8.  The  peritoneum.  It  must  be  remembered  that  the 
obliterated  umbilical  vessels  and  urachus,  passing  from  the 
fundus  of  the  bladder  to  the  umbilicus,  are  enclosed  in  a  fold 
of  the  parietal  peritoneum.  The  inferior  epigastric  artery, 
ascending  obliquely  from  Poupart's  ligament  to  the  posterior 
surface  of  the  rectus  muscle,  is  enclosed  in  a  similar  but  less 
prominent  fold.  The  fold  from  the  umbilicus  forming  the 
suspensory  ligament  of  the  liver  has  been  already  alluded  to. 
It  is  with  the  later  steps  of  the  operation  of  ovariotomy  that 
the  peritoneum  and  its  reflections  have  the  most  important 
relations.  In  connection  with  the  first  incision  it  is  only 
necessary  to  add  that  it  must  be  useless  to  carry  this  incision 
nearer  to  the  symphysis  pubis  than  the  reflection  of  the  peri- 
toneum from  the  anterior  abdominal  wall  to  the  bladder ;  and 
it  is  a  safe  rule  to  stop  short  of  this  point,  and  not  carry  the 
lowest  point  of  the  incision  nearer  than  two  inches  to  the 
symphysis  pubis. 


As  a  rule,  the  abdomen  is  tense,  and  the  incision  is  made 
with  an  ordinary  scalpel  held  in  the  first  position,  as  shown  in 
this  drawing.  If  the  operation  is  performed  soon  after  tapping, 
and  the  abdominal  walls  are  very  lax,  it  is  convenient  to  mark 


OPENING   THE   PERITONEUM  293 

the  exact  line  and  extent  of  the  incision  intended  to  be  made 
with  ink  or  chalk,  and  then,  holding  up  a  fold  of  integument, 
to  transfix  with  rather  a  long  bistoury,  and  complete  the  inci- 
sion of  the  skin  with  one  stroke  of  the  knife.  The  linea  alba 
and  any  fat  behind  the  recti  muscles  may  then  be  carefully 
divided  in  the  usual  way,  until  the  peritoneum  is  reached. 

If  there  is  any  fluid  free  in  the  peritoneal  cavity,  the  peri- 
toneum bulges  into  the  deep  gap  made  by  the  incision,  looking 
very  like  a  dark  thin-walled  cyst,  and  it  has  often  been  mis- 
taken for  a  cyst ;  extensive  separation  has  been  made  of  sup- 
posed adhesions,  while  the  operator  was  really  stripping  the 
peritoneum  from  the  abdominal  wall.  When  the  peritoneum 
bulges  as  just  described,  it  should  always  be  opened,  and  the 
fluid  allowed  to  escape,  which  with  the  waterproof  apron  may  be 
done  without  wetting  the  patient  or  its  running  over  the  floor, 
if  the  sheet  is  so  held  as  to  direct  the  fluid  into  the  foot-pan 
under  the  table.  Even  if  the  bulging  membrane  were  not  the 
peritoneum,  but  a  thin-walled  adherent  cyst,  no  harm  could  be 
done  by  this  puncture,  as  it  is  certainly  a  good  plan  to  empty 
the  cyst  before  separating  the  adhesions.  When  there  is  no 
fluid  free  in  the  peritoneal  cavity,  and  an  ovarian  cyst  is  free, 
it  is  necessary  to  divide  the  peritoneum  very  carefully,  or  the 
cyst  might  be  punctured  and  its  contents  discharged  into  the 
peritoneal  cavity.  The  peritoneum  should  be  raised  with  a 
hook  or  forceps,  the  double  sharp  hook  of  Mr.  Adams  answering 


the  purpose  perhaps  better  than  any  other  instrument.  The 
membrane  is  then  divided  by  one  or  two  horizontal  touches  of 
the  knife,  as  shown  in  the  next  drawing,  and  an  opening  made 
large  enough  to  admit  the  insertion  of  a  broad  director.  The 
instrument  known  as  Key's  hernia  director  is  that  which  I  have 
always  used.  The  end  is  rounded  in  imitation  of  a  finger-nail ; 
the  groove  does  not  extend  within  half  an  inch  of  the  point, 
and  thus  far  greater  safety  from  the  danger  of  wounding  over- 
lapping intestine  is  attained  than  by  the  use  of  the  ordinary 
narrow  directors,  where  the  groove  runs  quite  to  the  end. 
Upon  this  director  a  blunt-pointed  bistoury  is  passed,  and  the 


294 


INFLUENCE   OF   THE   LENGTH   OF  INCISION 


peritoneum  divided  to  the  full  extent  of  the  incision  in  the 
skin. 


The  following  table  shows  the  result  of  different  lengths  of 
incision  in  one  thousand  cases : — 


Ebsults  following  different  Lengths  of  Incision. 


First  five  hundred. 

Not  exceeding  6  inches 
Exceeding  6  inches 

Cases         Recoveries 
.     440            337 
.      60              36 

Deaths  Mortality  per  cent. 
103            23-4 
24             40 

Second  five  hundred. 

Not  exceeding  6  inches 
Exceeding  6  inches 

Cases         Recoveries 
.     489            388 
.       11                7 

Deaths  Mortality  per  cent. 
101            20-65 
4            36-36 

The  whole  thousand. 

Not  exceeding  6  inches 
Exceeding  6  inches 

Cases        Recoveries 
.     929            725 
.       71              43 

Deaths  Mortality  per  cent, 
204            21-95 
28            39-43 

Cases 

exceeding  7  inches  in  length. 

Inches 

7 

8 

9 
10 
20 

Cases 

35 

23 

9 

3 

1 

Recoveries         Deaths 

21                14 

16                  7 

5                  4 

1                   2 

0                  1 

Mortality  per  cent. 
40 

30-43 
44-44 
66-66 
100 

71 


43 


28 


39-43 


In  all  three  of  the  tables  of  my  thousand  operations  setting 
forth  the  results  following  different  lengths  of  incision — those 
of  the  first  500  cases,  those  of  the  second  500,  and  those  of 
the  entire  group — there  will  be  found  the  same  difference  of 


LONG   INCISION    PREFERABLE    TO   INCOMPLETE    OPERATION     295 

about  17  per  cent,  of  deaths  between  the  long  incisions  and 
the  short  incisions,  so  that  from  first  to  last  the  same  conditions 
have  been  influencing  the  mortality.  The  extent  of  the 
incision,  however,  is  little  else  than  an  indication  of  the 
gravity  of  the  case,  as  it  cannot  be  supposed  that  two  or  three 
inches  more  or  less  of  simple  division  of  the  parietes  of  the 
abdomen  would  augment  the  danger  to  this  amount.  But  while 
it  shows  that  the  case  is  serious  from  the  size  of  the  tumour, 
some  peculiarity  of  its  position,  or  the  character  of  the  adhesions, 
it  proves,  on  the  other  hand,  that  the  surgeon  is  cautiously 
facing  the  extra  call  upon  his  skill,  and  is  seeking  to  avoid  the 
additional  risk  of  working  in  the  dark,  of  being  obliged  to 
resort  to  undue  force  in  extraction,  of  causing  contusion  or 
laceration,  and  is  gaining  the  advantage  of  greater  control  over 
any  haemorrhage  that  may  happen  and  facility  in  the  toilette 
of  the  peritoneum. 

The  direct  mortality  of  these  long  incisions  has  not  exceeded 
39*43  per  cent.,  while  that  of  the  incomplete  cases  went  up 
to  43.  Here  I  am  speaking  of  '  incomplete  cases '  as  those 
where  incomplete  removal  of  a  tumour  has  been  the  character- 
istic feature  of  the  case.  In  a  mere  exploratory  incision  the 
mortality  is  almost  nil.  The  venture  of  the  '  major  operation  ' 
with  an  incision  of  from  seven  to  twenty  inches  in  length 
somewhat  counterbalances  the  difficulties  which  are  to  be  en- 
countered, and  at  any  rate  gives  the  patient  the  benefit  of  some 
3^  per  cent,  less  risk  than  she  would  have  to  bear  with  an 
abandoned  attempt.  Nor  must  we  overlook  the  fact  that  the 
survivors  of  this  operative  peril  of  43  per  cent.,  if  sometimes 
relieved  from  the  distress  of  certain  symptoms,  are  left  to  the 
misery  of  their  disappointed  hopes,  and  in  almost  all  instances 
to  a  lingering  but  certain  death.  In  contrast  to  this  fatality 
one  has  the  satisfaction  of  being  able  to  point  out  rather  more 
than  three-fifths  of  the  long  incision  cases  with  life  prolonged 
and  health  and  vitality  restored. 

Any  large  group  of  ovarian  tumours  may  be  ranged  in  these 
four  categories  :  1.  Those  in  which  a  simple  operation  has  a 
well-known  happy  result.  2.  Those  in  which  the  major  opera- 
tion gives  a  three  to  two  chance  of  renewed  life.  3.  Those  in 
which  an  incomplete  operation  hastens  the  death  of  a  large 
proportion  and  leaves  the  rest  to  their  fate  with  the  aggravation 


296         PRECAUTIONS   IN   OPENING   THE  ABDOMINAL  CAVITY 

of  blighted  anticipations ;  and  4,  those  in  which  an  explora- 
tory incision  only  confirms  the  worst  prognostications  and  leaves 
the  patient  scarcely  better  or  worse  for  the  incisions  or  very 
much  as  if  she  had  been  tapped  only.  Experience  thus  leads 
us  to  believe  that  when  in  unpromising  circumstances  anything 
has  to  be  done,  a  little  freedom  and  boldness  in  operation  is 
better  practice  than,  as  in  the  earlier  days  of  ovariotomy, 
stopping  short  in  sight  of  what  appeared  desperate  obstacles, 
with  only  a  moderate  opening  for  investigation  and  less  than 
space  enough  for  useful  manoeuvring.  More  must  be  said  on 
this  subject  in  the  chapter  on  incomplete  operations,  especially 
with  reference  to  extra-ovarian  and  extra-peritoneal  cysts. 

The  smooth  pearly  aspect  of  most  ovarian  tumours  is 
sufficiently  characteristic  for  immediate  recognition,  and  free 
movement  of  the  cyst  is  often  visible.  But,  when  a  cyst  is 
adherent,  it  is  often  extremely  difficult  to  find  out  the  exact 
limits  or  boundary  between  cyst  and  peritoneum,  and,  rather 
than  make  any  improper  or  dangerous  separation,  it  is  better 
to  extend  the  incision  upwards  and  downwards  until  some  point 
is  reached  where  the  cyst  is  not  adherent.  From  that  point 
separation  of  adhesions  may  be  commenced.  When  there  is 
much  fat  in  the  abdominal  wall,  either  in  front  of  or  behind 
the  recti  muscles,  this  should  be  divided  by  as  clean  a  cut  as 
possible,  going  through  nearly  the  whole  thickness  of  fat  by 
one  stroke  of  the  knife,  for,  if  the  fat  be  much  disturbed, 
troublesome  suppuration  about  the  wound  is  very  likely  to 
occur.  During  the  progress  of  the  incision  bleeding  may  be 
tolerably  free,  but  very  often  scarcely  any  blood  is  lost ;  and, 
as  soon  as  the  incision  has  reached  the  peritoneum,  the  wound 
should  be  carefully  cleansed  from  the  blood  by  soft  linen  or 
sponges.  Any  vessel  seen  to  bleed  should  be  compressed  by 
pressure-forceps.  It  is  important  to  stop  all  bleeding  from  the 
wound  before  the  peritoneum  is  opened.  It  is  seldom  that 
any  large  vessel  is  divided,  but  if  the  compression  of  the 
forceps  or  torsion  does  not  at  once  stop  bleeding,  one  or  more 
ligatures  may  be  used  and  both  ends  may  be  cut  off  short  close 
to  the  knot. 

SEPARATION   OF   THE   CYST. 

I  have  just  said  that  if  a  cyst  is  so  closely  adherent  that 


SEPAKATION    OF   ADHESIONS 


297 


it  is  difficult  to  ascertain  its  exact  boundaries,  it  is  better  to 
empty  it  before  attempting  to  separate  it,  than  to  run  any 
risk  either  of  separating  the  peritoneum  from  the  abdominal 
wall,  or  of  so  rupturing  the  cyst  that  its  contents  might 
escape  into  the  peritoneal  cavity.  And  adhesions  to  the  intes- 
tine or  omentum,  especially  those  at  the  posterior  part  of 
the  cyst,  are  also  better  left  until  the  cyst  is  emptied  and 
drawn  out,  and  the  separation  only  completed  when  the  parts 
to  be  separated  are  in  full  view.  When  adhesions  are  loose, 
or  not  extensive,  and  the  cyst  has  been  distinctly  made  out 
after   the    division    of  the   peritoneum,   the    adhesions  may 


,!T  3-  s 


generally  be  easily  separated  by  one  or  two  fingers,  or  by 
inserting  the  whole  hand  between  the  cyst  and  the  abdominal 
wall — the  palmar  surface  next  the  tumour,  and  the  fingers 
curved  to  adapt  the  shape  of  the  hand  to  the  convexity  of  the 
cyst.  Sometimes  extensive  adhesions  yield  before  a  very  slight 
force,  but  very  considerable  effort  is  occasionally  required  to 
break  them  down.  Adhesions  are  very  rarely  so  firm  that  knife 
or  scissors  become  necessary  to  complete  their  separation  ;  when 
this  is  the  case,  it  is  better  to  cut  away  some  small  portion  of 
the  cyst  and  leave  it  adhering  to  the  intestine  or  some  other 
viscus,  than  to  do  any  damage  by  attempting  to  take  away 
every  fragment  of  the  cyst.     I  have,  however,  very  rarely  done 


298  TAPPING   THE   CYST 

this,  as,  after  the  cyst  has  been  separated  from  the  abdominal 
wall,  emptied,  and  drawn  out  with  the  adhering  portions  of  in- 
testine and  omentum,  I  have  almost  always  been  able  to  make 
complete  separation,  although  great  care  has  often  been  neces- 
sary to  avoid  injury  to  the  intestine.  I  have  twice  opened 
intestine  when  separating  adhesions,  but  accurate  adaptation 
of  the  peritoneal  coat  by  suture  has  prevented  any  mischief. 
In  one  case  I  removed  about  three  inches  of  diseased  and  adhe- 
rent intestine,  and  obtained  complete  union  of  the  open  ends  to- 
gether by  two  rows  of  suture  through  the  peritoneal  coat  only. 
Occasionally,  instead  of  separating  adhering  omentum,  it  is 
better  to  divide  it  at  some  unattached  point,  after  the  applica- 
tion of  a  ligature  or  pressure-forceps,  allowing  the  adhering 
portion   to   be   removed  with  the  cyst.     The   suppression   of 


bleeding  from  separated  omentum  or  parietal  adhesions  is  left 
until  after  the  emptying  of  the  cyst,  securing  the  pedicle,  and 
cutting  away  the  tumour. 

When  the  tumour  is  found  free  from  adhesions,  or  after 
the  separation  of  slight  adhesions,  the  next  step  is  to  empty 
the  cyst.  The  syphon  trocar  with  spring-hooks  has  been  already 
described.  This  instrument,  held  in  the  right  hand,  should 
be  pushed  into  the  most  prominent  part  of  the  cyst,  if  this 
appear  to  be  simple ;  if  multilocular,  into  that  chamber  which 
is  likely  to  contain  the  largest  quantity  of  fluid,  and  the  point 
is  to  be  drawn  within  the  canula  by  means  of  the  thumb-piece. 

After  a  portion  of  the  fluid  has  been  drained  off,  and  the 
cyst  has  become  more  flaccid,  it  is  drawn  higher  up  over  the 
canula  by  means  of  hooks  or  the  tenaculum,  and  fixed  between 


WITHDRAWAL    OF   THE    CYST  299 

the  prongs  of  the  spring-hooks,  which,  if  properly  adjusted, 
will  hold  the  cyst-wall  tightly  around  the  canula.  After  the 
first  cavity  has  been  emptied,  a  second,  a  third,  and  more  if 
necessary,  may  be  tapped  successively  without  removing  the 
canula  from  its  hold,  merely  by  pushing  the  trocar  forward  and 
thrusting  it  through  the  septum  which  separates  the  emptied 
from  the  adjacent  full  cavity.  In  this  manner  the  whole 
tumour  may  be  emptied  of  its  fluid  contents  and  its  bulk  so 
reduced  that  it  may  be  drawn  through  the  abdominal  opening 
without  undue  force.  In  a  case  where  there  are  several  cysts 
which  cannot  be  tapped  one  through  the  other,  they  must  be 
emptied  singly,  either  by  the  same  trocar  or  by  another.  Great 
care  must  be  taken,  if  the  same  trocar  be  used,  lest  some  re- 
maining fluid  should  escape  through  the  punctured  opening 
into  the  abdominal  cavity. 

Having  succeeded  in  reducing  sufficiently  the  size  of  the 
tumour,  the  surgeon  then  draws  it  through  the  incision,  at  the 


same  time  breaking  down  any  adhesions  which  have  not  been 
separated  before.  The  assistant  opposite  to  the  operator  now 
places  his  hands  on  either  side  of  the  incision,  and  prevents  the 
prolapse  of  the  viscera  by  carefully  keeping  the  edges  of  the 
incision  in  close  approximation.  He  does  this  best  by  placing 
the  middle  finger  of  his  right  hand  inside  the  abdomen,  hooking 
up  the  abdominal  wall,  and  then,  by  the  thumb  on  one  side  of 
the  opening  and  the  forefinger  on  the  other  side,  he  holds  the 
edges  of  the  opening  close  together.  And  he  should  not  allow 
his  attention  to  be  diverted  from  this  very  important  part  of 
his  duty.  The  assistant  at  the  operator's  left  hand  supports 
the  cyst  until  it  is  completely  separated,  and  then  receives  it 
in  a  towel  or  basin.     No  traction  whatever  is  permitted,  and 


300  REDUCING   THE   BULK   OF   THE   TUMOUR 

the  greatest  precaution  ought  to  be  observed  in  this  respect 
when  the  pedicle  is  short,  and  when  there  remain  undivided 
adhesions. 

In  order  to  lessen  the  weight  of  the  tumour,  cysts  which 
had  not  been  emptied  before  may  be  punctured,  and  secondary 
cysts,  if  the  septa  are  thin,  may  be  broken  down  by  the  hand, 
as  shown  below.  Great  care  ought  to  be  taken  that  nothing 
gravitates  into  the  abdominal  cavity. 

But  it  will  not  be  always  possible  to  reduce  the  bulk  of  the 
tumour  sufficiently  to  bring  it  through  the  original  incision. 
Tumours  are  sometimes  met  with  which  consist  of  solid  or  semi- 
solid unyielding  masses,  or  they  are  divided  by  trabecule  into 
small  cavities  filled  with  viscid,  colloid  substance,  which  cannot 


be  broken  down,  and  will  not  pass  through  the  canula.  It  will 
therefore  become  necessary  to  enlarge  the  incision  upwards. 
This  is  less  dangerous  than  any  attempt  at  squeezing  a  large 
tumour  through  a  narrow  outlet ;  either  the  cyst  may  burst, 
and  its  contents  escape  into  the  abdominal  cavity,  or  the  edges 
of  the  wound  are  so  bruised  that  union  by  first  intention  might 
be  prevented,  or  the  peritoneum  so  injured  that  fatal  peritonitis 
or  gangrene  may  result. 

In  a  few  of  my  earliest  cases  I  followed  the  practice  of 
previous  operators  of  having  flannels  wrung  out  of  water  at  96° 
carefully  wrapped  round  the  cyst  or  any  intestine  that  escaped, 
and  to  protect  the  peritoneal  cavity.  But  I  discontinued  this 
practice,  finding  that  it  was  impossible  to  prevent  small  fila- 
ments of  wool  separating  from  the  flannel  and  adhering  to  the 
peritoneum.     Then  I  used  soft  linen  towels,  but  for  many  years 


USE   OF  LARGE   FLAT   SPONGE  301 

past  only  soft  sponges.  As  the  cyst  is  drawn  through  the 
opening,  a  thin  flat  sponge,  6  or  8  inches  in  length  and  about 
4  in  breadth,  should  be  passed  inwards  and  left  between  the 
intestines  and  the  open  abdominal  wall.  This  serves  the 
double  purpose  of  preventing  escape  of  intestines,  and  protect- 
ing the  cavity  from  the  entrance  of  anything  from  outside,  or 
from  cooling  when  spray  is  used. 


302  TREATMENT   OF  THE   PEDICLE 


CHAPTER   IX. 

TREATMENT  OF  THE  PEDICLE  ;  SPONGING  OF  THE  PERITONEUM 
CLOSURE  OF  THE  WOUND  ;  ACCIDENTS  DURING  OPERATION. 

The  cyst  or  tumour  having  been  drawn  out  of  the  abdomen, 
any  omentum  or  intestine  adhering  to  its  peritoneal  coat 
separated,  and  any  bleeding  vessel  in  the  part  separated  secured, 
the  intestines  and  peritoneal  cavity  protected  as  just  described 
by  a  flat  sponge,  the  next  step  is  to  secure  the  pedicle — the 
structure  and  varieties  of  which  have  been  already  described. 
The  operator  will  do  this  in  different  ways,  according  to  his 
intention  to  adopt  the  intra-peritoneal  or  the  extra-peritoneal 
method. 

The  older  operators,  McDowell  and  Clay  especially,  adopted 
a  plan  which  may  be  considered  a  combination  of  both  methods. 
The  pedicle  was  tied  with  silk  or  whipcord,  the  tumour  cut 
away,  and  the  tied  pedicle  was  left  low  down  in  the  abdominal 
cavity,  surrounded  by  the  ligature,  while  the  ends  of  the  liga- 
ture were  brought  out  between  the  edges  of  the  closed  wound. 
Half  or  three-quarters  of  an  inch  of  the  lower  angle  of  the 
wound  were  left  unclosed  to  admit  of  the  passage  of  the  liga- 
ture thread,  to  keep  a  space  for  discharge,  and  for  the  removal 
of  the  ligatures  and  of  the  tissues  strangulated  by  them  as 
soon  as  separation  was  complete. 

The  intra-peritoneal  method  was  originated,  in  1821,  by 
Dr.  Nathan  Smith,  of  Baltimore,  who  tied  two  arteries  in  the 
omentum  with  strips  of  leather  from  a  kid  glove,  and  also  tied 
two  arteries  in  the  pedicle  by  leather  ligatures,  and  after 
removal  of  the  tumour,  cut  off  the  ends  of  the  ligatures  short, 
and  left  them  within  the  peritoneal  cavity,  closing  up  the 
wound  completely.  He  was  followed  by  Dr.  Rogers,  of  New 
York,  who,  in  1830,  also  tied  separately  several  large  vessels 


EXTRA-PERITONEAL  TREATMENT  303 

in  the  pedicle,  cut  off  the  ligatures  '  close  to  the  knot,  and 
left  them  to  absorption.'  In  England  this  method  was  revived 
by  Dr.  Tyler  Smith,  was  followed  by  many  operators,  and  after 
preference  for  several  years  of  the  extra-peritoneal  method  has 
come  into  general  favour  since  the  adoption  of  the  antiseptic 
system. 

The  other  intra-peritoneal  methods  include  the  use  of  the 
cautery,  the  ecraseur,  the  twisting  off  of  the  tumour,  torsion 
of  its  vessels,  or  the  separate  ligature  of  the  vessels  of  the 
pedicle,  rather  than  of  the  pedicle  itself.  In  cases  where  there 
is  no  pedicle  and  the  cyst  has  to  be  enucleated  from  between 
the  layers  of  the  broad  ligament,  ligature  of  bleeding  vessels, 
or  of  parts  of  the  broad  ligament  after  removal,  have  almost 
compelled  the  adoption  of  the  intra-peritoneal  method,  since 
the  danger  of  leaving  the  ends  of  the  ligature  passing  outwards 
has  been  understood. 

In  adopting  the  extra-peritoneal  method,  instead  of  shutting 
up  the  pedicle  with  the  ligature,  or  the  eschar  made  by  the 
cautery,  within  the  peritoneal  cavity,  the  pedicle  and  the  clamp 
or  ligature  securing  it  are  carefully  fixed  outside  the  closed 
wound. 

The  following  extract  from  clinical  remarks  which  I  made 
at  the  '  Samaritan  Hospital '  in  October  1868,  and  which  were 
published  soon  after  in  the  '  Medical  Times  and  Gazette,'  may 
be  taken  as  the  expression  of  an  opinion  which  subsequent 
experience  confirmed,  until  the  conclusions  were  modified  by 
antiseptics,  as  to  the  relative  value  of  the  extra-  and  intra- 
peritoneal methods  of  dealing  with  the  pedicle. 

'  Since  last  October  I  have  completed  the  operation  of 
ovariotomy  in  this  hospital  in  thirty-six  cases,  besides  one  case 
in  which  I  performed  the  operation  successfully  for  the  second 
time  on  the  same  patient.  Of  the  thirty-six  women,  thirty-one 
recovered  and  five  died.  And  it  is  a  remarkable  fact  that  in 
every  case  in  which  the  pedicle  was  long  enough  to  enable  me 
to  use  the  clamp  the  patient  recovered.  There  were  thirty  of 
these  cases — thirty  clamp  cases  in  one  year  without  a  single 
death.  In  two  cases  I  used  the  cautery.  One  of  the  patients 
recovered,  and  one  died.  In  four  cases  I  tied  the  pedicle,  and 
returned  it  into  the  cavity  of  the  abdomen  after  cutting  off  the 
ends  of  the  ligature.     All  these  four  patients  died.     Two  of 


304  EXTRA-PERITONEAL  TREATMENT 

them  must  have  died,  I  think,  in  whatever  manner  the  pedicle 
had  been  treated.   They  were  almost  hopeless  cases,  and  the  ope- 
ration was  done  as  a  forlorn  hope.    In  one  case  the  patient  was 
sinking  fast  from  septicaemia,  a  cyst  filled  with  fetid  fluid  and 
poisonous  gas  having  been  washed  out  repeatedly,  but  ineffec- 
tually, with  carbolic  acid,  and  it  was  at  last  removed  with  only 
the  very  faintest  hope  of  saving  life.     In  the  other  case,  exten- 
sive pelvic  adhesions  and  disease  of  both  ovaries  had  been  pretty 
accurately  made  out,  and  had  led  to  repeated  tappings  rather 
than  ovariotomy.     But  at  length,  when  tappings  became  of  no 
avail,  the  cysts  were  removed,  with  some  slight  hope  but  with 
far  greater  apprehension.     A  clamp  could  not  be  used  in  either 
case.     The  pedicles  were  too  short.     The  cautery  might  have 
been  used ;  but  the  pedicles  were  of  the  kind  where  the  cautery 
is  often  ineffectual  in  stopping  bleeding — broad,  thin,  mem- 
branous attachments,  with  large  vessels.     In  such  cases  the 
ligature  succeeds  well  in  stopping  bleeding ;  but  whether  the 
ends  are  left  hanging  out  through  the  opening  in  the  abdominal 
wall,  or  are  cut  off  short  and  returned  with  the  pedicle,  the 
results  in  my  hands  have  been  almost  equally  unsatisfactory. 
Other  operators  have  been  much  more  satisfied  with  the  ligature 
than  I  have  been,  and  every  one  must  be  guided  very  much  by 
his  own  experience.     But  when  I  look  back  over  the  work  of 
the  past  year  in  this  hospital,  where  all  the  patients  have  been 
treated  in  all  other  circumstances  under  similar  conditions,  and 
find  no  single  death  in  thirty  clamp  cases,  but  every  one  a 
recovery,  while  of  six  cases  treated  otherwise  five  die,  you  will 
hardly  wonder  that  I  use  the  clamp  whenever  I  can,  especially 
as  very  similar  results  have  been  obtained  in  private  practice. 
It  is  true,  as  I  have  just  said,  that  two  of  these  five  deaths 
would  probably  have  happened  even  if  I  had  been  able  to  use  a 
clamp.      But  three  of  the  deaths  I  attribute  principally,  or 
entirely,  to  the  fact  that,  as  I  was  unable  to  secure  the  pedicle 
outside  the  peritoneal  cavity,  I  was  driven  against  my  will  to  the 
cautery  or  the  ligature.     Twice  I  used  the  cautery.   In  one  case 
it  stopped  all  bleeding,  and  the  patient  recovered.     In  another 
it  only  stopped  the  smaller  vessels,  the  larger  having  to  be  tied, 
and  this  patient  died ;  so  that  her  death  might  be  added  to  that 
of  the  four  who  died  after  the  return  of  the  tied  pedicle.    Or  if, 
as  I  think  it  is  fair  to  do,  we  put  aside  (so  far  as  the  treatment 


CHANGES   IN    PEDICLE   AFTER  LIGATURE  305 

of  the  pedicle  is  concerned)  the  two  cases  which  probably  must 
have  died  however  the  pedicle  had  been  treated,  we  have  three 
cases  where  death  followed  the  use  of  the  ligature  ;  and,  so  far 
as  I  can  judge  from  observation  of  similar  cases,  these  three 
patients  would  probably  have  recovered  if  the  pedicles  had  been 
long  enough  for  a  clamp  to  have  been  applied  and  fixed  outside 
the  peritoneal  cavity.'  It  must  be  remembered  that  this  was 
written  ten  years  before  I  began  to  adopt  what  are  known  as 
the  Listerian  details,  and  the  next  paragraph  was  also  written 
without  regard  to  the  effects  of  these  details. 

The  question,  what  becomes  of  a  ligature,  and  of  the  tissues 
strangulated  by  it,  when  closed  up  in  the  peritoneal  cavity,  is  a 
very  important  one.  It  is  quite  certain  that  the  changes  differ 
very  widely  from  those  which  follow  the  use  of  the  ligature 
when  the  ends  are  left  to  pass  out  through  the  partially  closed 
wound.  In  this  case  they  lead  to  free  discharge  of  serum  or 
pus,  until  the  separation  of  the  ligature  and  the  slough.  What- 
ever may  be  the  material  of  the  ligature,  the  tissues  strangu- 
lated by  it  come  away  after  a  longer  or  shorter  process  of  sup- 
puration ;  and  if  anything  like  what  goes  on  outside  the  body 
when  one  of  the  extra-peritoneal  methods  is  adopted,  or  when 
the  wound  is  left  open  for  the  ligatures,  went  on  when  the 
wound  is  closed,  no  patient  could  possibly  survive  the  process. 
She  would  almost  certainly  be  poisoned  by  absorption  of  the 
fetid  products  of  the  decomposing  stump.  A  very  different 
series  of  changes  must  go  on  when  the  wound  is  closed  and 
access  of  air  shut  off.  Experience  shows  that  many  patients  do 
survive  the  process  ;  and  examination  of  those  who  have  died 
has  shown  that  a  pedicle  secured  by  a  silk  ligature  has  been 
found  some  days  afterwards,  either  first,  surrounded  by  coils  of 
adhering  intestine ;  second,  as  the  centre  of  a  purulent  cavity ; 
third,  very  little  altered,  with  the  ligature  deeply  imbedded 
within  it;  and  fourth,  completely  dead  or  gangrenous.  All 
these  different  conditions  I  have  actually  seen  accompanied  by 
more  or  less  evidence  of  peritonitis,  and  depending  more,  I 
believe,  on  the  general  health  of  the  patient  and  the  conditions 
in  which  she  was  placed,  than  upon  any  difference  in  the 
material  of  the  ligature  or  the  mode  of  its  application.  I  must 
now,  of  course,  add  that  among  the  conditions  in  which  the 

x 


306  FOREIGN   BODIES   IN   THE   PERITONEAL   CAVITY 

patient  is  placed,  we  attach  paramount  importance  to  the 
presence  or  absence  of  infective  or  putrefying  matter. 

Our  knowledge  of  this  subject  has  been  greatly  increased 
by  the  report  of  the  experiments  of  Spiegelberg  and  Waldeyer, 
published  in  1868,  in  Virchow's  '  Archives.'  Their  experiments 
were  arranged  in  two  series  :  1.  Excision  of  portions  of  the 
horns  of  the  uterus  of  bitches,  leaving  the  ligatures  in  the 
peritoneal  cavity  ;  and  2.  Eemoval  of  portions  of  the  uterus  by 
the  galvanic  cautery.  The  conclusions  of  the  experimenters  are 
that  small  foreign  bodies  may  be  left  in  the  peritoneal  cavity 
without  danger,  and  that  strangulated  and  cauterized  tissues 
do  not  become  gangrenous  and  are  not  injurious  to  neighbour- 
ing parts,  provided  only  that  the  abdominal  cavity  is  perfectly 
closed. 

We  may  ask  how  far  the  experiments  bear  out  the  conclu- 
sions ;  and  first  as  to  the  changes  which  foreign  bodies  them- 
selves undergo  when  left  in  the  peritoneal  cavity. 

Ligatures,  either  of  silk  or  hemp,  up  to  about  the  twenty- 
first  day,  scarcely  show  any  change,  except  some  softening  of 
the  hemp.  '  Between  the  particular  fibres  which  compose  the 
ligature  thread,  a  number  of  young  cells  insinuate  themselves, 
separating  the  threads  from  each  other  in  some  places  in  a  re- 
markable manner,  and  evidently  penetrating  from  neighbour- 
ing parts.  After  a  long  time,  the  fibres  are  in  this  manner 
completely  separated  from  each  other,  the  knots  loosened,  the 
threads  totally  unravelled.  Where  a  ligature  had  cut  through, 
in  several  cases  its  track  was  marked  by  the  remnants  of  single 
fibres.' 

Then,  as  to  the  changes  produced  by  the  ligature  in  and 
about  the  parts  where  it  is  applied.  The  Breslau  Professors 
found  the  ligatures  either  '(1)  closely  encapsuled  by  newly 
formed  cellular  tissue;  or  (2)  free  in  the  peritoneal  cavity, 
having  slipped  off  from  the  tied  parts;  or  (3)  free  as  if  swim- 
ming in  a  small  cystic  cavity  of  the  stump.'  I  translate  the 
word  Schniirstucke,  or  the  end  of  the  pedicle  between  the  spot 
where  it  has  been  divided  and  the  spot  where  the  ligature  is 
applied,  as  stump,  because,  for  want  of  a  better  term,  we  say 
'  the  stump  of  a  pedicle '  when  we  wish  to  describe  that  part 
of  it  which  is  surrounded  by  a  ligature  or  enclosed  between  the 
blades  of  a  clamp  and  is  left  after  cutting  away  the  tumour. 


CAPSULATION   OF  LIGATURES  307 

These  authors  also  use  two  other  words — mesometrium  and 
mesovarium.  The  former  implies  what  we  term  the  broad 
ligament. 

Among  the  observations  on  the  capsulation  of  ligatures,  we 
find  an  account  of  an  interesting  case  where  a  ligature  had 
surrounded  the  body  of  the  uterus,  which  was  cut  away  nearly 
an  inch  beyond ;  and  on  the  twenty-eighth  day  the  ligature 
was  found  sunk  into  the  substance  of  the  uterus,  which  it  had 
not  entirely  cut  through.  The  fibres  of  the  ligature  were  sur- 
rounded on  all  sides  by  new  granulations,  and  there  was  not  a 
trace  of  mortified  tissue  elements  to  be  found  either  within  or 
around  the  ring  of  the  thread.  In  another  case,  where  liga- 
tures were  applied  to  the  uterus  before  cauterization,  micro- 
scopic examination  fourteen  days  afterwards  showed  one  of  the 
ligatures  closely  surrounded  by  granulating  tissue,  the  cells  of 
which  lay  in  great  numbers  between  the  fibres  of  the  silk.  Not 
a  particle  of  mortified  tissue  could  be  found  anywhere.  '  Liga- 
tures on  vessels  were  found  after  four  weeks  enclosed  in  per- 
fectly developed  connective  tissue.  Looking  on  the  mesome- 
trium, small  smooth  nodules  were  observed,  corresponding  in 
size  to  the  ligatures  ;  but  no  difference  could  be  found  any- 
where in  the  smoothness  of  the  serous  membrane  covering  the 
knots  and  that  in  the  neighbourhood.  It  appeared  as  if  the 
character  of  serous  membrane  upon  the  outer  surface  of  the 
connective  tissue  enclosing  the  knots  had  been  completely  re- 
established, and  the  knots  had  been  simply  inbedded  between 
the  two  layers  of  the  mesometrium.' 

In  one  case,  where  a  ligature  had  completely  slipped  off 
from  the  part  which  it  had  surrounded,  and  had  been  free  in 
the  peritoneal  cavity,  it  had  become  firmly  connected  with  a 
neighbouring  coil  of  intestine  by  means  of  young  cells,  spring- 
ing up  from  the  serous  membrane,  which  had  penetrated  be- 
tween the  fibres  of  the  thread,  so  that  there  was  almost  an 
organic  union  between  the  surface  of  the  intestine  and  the 
knot  of  the  ligature. 

Where  a  ligature  had  to  cut  through  a  thick  substance — as 
the  body  of  the  uterus  or  one  of  its  horns — the  track  of  the 
ligature  could  be  distinctly  seen  on  section,  with  help  from  a 
strong  lens,  as  a  fine  gray  line.  It  began  as  a  slight  indenta- 
tion of  the  peritoneal  coat  corresponding  to  the  place  where 

x  2 


308  THE   LOCAL  EFFECTS   OF   LIGATURES 

the  ligature  first  caught.  As  early  as  the  fifth  day,  this  inden- 
tation had  become  so  shallow  as  to  be  in  no  proportion  to  the 
deeply  grooved  ring  round  the  tissues  powerfully  constricted 
by  the  ligature.  Under  a  higher  magnifying  power  the  deli- 
cate line  is  seen  to  be  formed  by  a  streak  of  new  cells,  which 
mark  the  track  of  the  ligature  ;  but  no  trace  can  be  seen  of 
mortified  particles  of  tissue.  'It  appears,  therefore,  that  a 
ligature  divides  tissues  in  a  very  gentle  manner,  as  if  the  tissue 
elements  became  loosened  and  separated  before  it,  while  new 
cells  are  formed,  and  the  gap  behind  it  closes,  so  that  the 
divided  surface  is  scarcely  ever  exposed,  at  least  within  the 
peritoneal  cavity.  The  first  occurrence  after  the  application  of 
a  ligature  is  evidently  the  union  of  the  two  borders  of  the  ring 
cut  by  the  ligature.  In  this  way  the  thread  is  soon  shut  off 
from  communication  with  surrounding  parts,  and  then  lies 
completely  shut  up  in  a  circular  canal.  We  have  seen  this 
very  clearly  in  two  post-mortem  examinations  made  three  days 
after  ovariotomy.  There  were  already  abundant  groups  of  new 
tissue  sprouting  up  from  the  neighbourhood  over  the  ligatures, 
which  had  cut  deeply  into  the  pedicle,  and  almost  completely 
covering  it.  In  the  new  granulation  tissue  numerous  blood- 
vessels can  be  discovered  very  early,  so  that  the  transition  to 
permanent  tissue  is  very  soon  effected.' 

The  authors  conclude  from  their  experiments  that  ligatures 
enclosed  in  the  peritoneal  cavity  do  not  lead  to  any  evidence 
of  acute  local  peritonitis,  and,  so  far  as  the  tissues  of  the 
uterus  and  mesometrium  are  concerned,  can  hardly  be  regarded 
as  foreign  bodies.  They  nowhere  induce  processes  of  mortifi- 
cation in  these  tissues  ;  but,  on  the  contrary,-  are  enclosed  and 
encapsuled  on  every  side  by  them — in  dogs  as  soon  as  the 
eighth  day. 

We  now  come  to  some  very  interesting  observations,  well 
worthy  of  careful  consideration,  upon  the  changes  in  the  sur- 
face of  the  divided  parts  of  the  uterus.  After  a  few  days — from 
four  to  six — no  free  divided  surface  could  be  seen.  Sur- 
rounding portions  of  the  mesometrium,  bladder,  or  coils  of 
intestine  rapidly  adhere  to  it.  In  one  case,  after  nine  days, 
numerous  blood-vessels  were  observed  running  between  the 
coats  of  the  bladder  and  the  uterus.  In  another  case,  after 
twenty-one  days,  the  spot   from  whence   an  ovary  had  been 


EXAMINATION    OF   LIGATURES    AFTER    OVARIOTOMY  309 

removed  could  not  be  detected,  so  perfectly  smooth  and  free 
from  any  cicatrix  was  the  posterior  abdominal  wall  where  the 
ovary  had  been.  In  another  case,  six  days  after  operation,  the 
cut  end  of  the  left  horn  of  the  uterus  was  found  soldered 
between  two  coils  of  intestine.  The  mesometrium  was  drawn 
in  between  them  and  united  with  their  coats  and  mesentery. 
The  divided  horn  of  the  uterus  itself  was  also  partly  adherent 
to  the  intestine. 

The  most  complete  and  extensive  adhesions  of  the  uterus 
were  always  with  its  own  mesometrium.  This  was  always 
observed,  even  when  other  organs  were  also  adherent.  The  cut 
surface  of  the  uterus  falls  upon  the  neighbouring  mesometrium ; 
new  cells  spring  up  from  the  latter  and  unite  with  the  granu- 
lations from  the  uterine  surface.  Afterwards,  retraction  of  the 
new-formed  granulation  tissue  draws  the  stump  of  the  uterus 
more  and  more  within  the  folds  of  the  mesometrium,  until  it  is 
completely  surrounded.  A  very  free  vascular  communication 
has  been  observed  between  their  united  surfaces.  The  authors 
never  observed  any  divided  surface  either  free  or  with  shreds  of 
gangrenous  tissue  about  it. 

Similar  conditions  were  observed  in  the  two  ovariotomy 
cases  just  alluded  to.  The  divided  surfaces  of  both  pedicles 
were  on  the  third  day  perfectly  fresh,  without  any  gangrenous 
appearance.  In  the  first  case,  where  both  ovaries  were  re- 
moved, both  pedicles  were  free  and  directed  upwards ;  in  the 
second  case,  the  divided  surface  of  the  pedicle  was  in  contact 
with  the  peritoneal  covering  of  the  psoas  magnus,  with  which  it 
was  connected  by  new  cells,  and  without  any  trace  of  gangrene. 

Passing  on  to  the  consideration  of  the  effects  produced  by 
the  ligature  on  the  part  enclosed  by  it — the  stump — the  authors 
say  that  when  a  blood-vessel  is  tied,  the  strangulated  end  of  the 
vessel  dies  and  is  thrown  off  with  the  ligature.  Hence  the  rule 
not  to  tie  a  vessel  far  from  its  cut  end,  but  as  near  as  it  can  be 
done  with  certainty  to  stop  bleeding.  So  that  when  it  was 
proposed  to  tie  a  pedicle  of  an  ovarian  tumour  and  leave 
ligature  and  stump  in  the  peritoneal  cavity,  it  was  feared  that 
there  would  be  great  danger  from  the  death  of  the  strangulated 
stump.  At  the  same  time,  if  the  stump  were  left  very  short, 
by  cutting  away  the  tumour  close  to  the  ligature,  it  was  feared 
that  the  ligature  might  slip  off,  and  internal  bleeding  take 


310  EXAMINATION   OF   LIGATURES   AFTER   OVARIOTOMY 

place.  The  authors  consider  that  their  experiments  prove 
these  fears  to  be  exaggerated — at  least  they  establish  the  fact 
that  in  dogs  there  is  no  gangrenous  change  in  the  stump,  nor 
any  trace  of  mortification  either  on  the  divided  surfaces  or  on 
the  parts  behind  the  ligature.  In  the  case  where  the  divided 
end  of  the  uterus  adhered  between  two  coils  of  intestine,  the 
stump  had  contracted  to  a  nodule  hardly  as  large  as  a  pea, 
consisting  of  a  part  of  the  uterine  wall  with  its  mucous  mem- 
brane everted,  and  containing  all  its  structural  elements, 
including  the  utricular  glands,  completely  unaltered.  The 
openings  of  these  glands  had  thus  been  brought  free  in  the 
peritoneal  cavity. 

Larger  stumps  were  enveloped  in  folds  of  the  mesometrium. 
Their  canals  were  almost  always  pervious,  and  in  some  had 
become  dilated  into  a  sort  of  cyst  with  muco-purulent  con- 
tents. Sometimes  the  ligature-knots  lay  within  these  cysts, 
the  textures  of  the  walls  remaining  almost  unaltered,  and  the 
mucus-  and  pus-corpuscles  showing  very  little  retrograde  meta- 
morphosis. In  most  cases  there  remained  a  narrow  communi- 
cation opening  between  the  cavity  in  the  stump  and  the  rest  of 
the  uterus.  In  two  cases  the  cavity  of  the  stump  was  oblite- 
rated and  filled  with  young  granulation  tissue,  in  which  no 
epithelium  of  the  uterine  cavity  could  be  found,  although 
there  were  remnants  of  utricular  glands.  All  this  proves  that 
the  textural  alterations  take  place  by  simple  retrograde  meta- 
morphosis, fatty  degeneration,  and  gradual  absorption,  with  a 
formation  of  cells  which  become  permanently  organised  tissue, 
but  without  the  occurrence  of  any  violent  inflammatory  or 
gangrenous  changes. 

The  authors  have  not  much  to  say  about  the  changes  in  the 
surfaces  cauterized.  Only  three  animals  were  subjected  to 
experiment,  and  these  were  killed  on  the  sixth,  fourteenth, 
and  twenty-sixth  days  after  the  application  of  the  cautery. 
On  the  sixth  day  the  cauterized  surface  of  the  central  part  of 
the  uterus  appeared  quite  fresh,  beset  with  numerous  small 
brown-black  particles  of  animal  charcoal,  not  softened,  but 
firm  and  hard.  At  a  depth  of  two  or  three  millimetres,  the 
uterine  tissue  was  coloured  reddish,  as  if  from  imbibition  of 
the  colouring  matter  of  blood.  The  uterine  cavity  was  shut 
off  from  the  peritoneal  cavity,  but  rather  by  the  firm  aggluti- 


STRUCTUEAL   CHANGES   IN  CAUTERIZED   STUMPS  311 

nation  of  the  tissues  of  the  cauterized  surface  than  by  granula- 
tions, none  of  which  could  yet  be  seen.  The  microscope 
showed  the  tissue  of  the  cauterized  part  to  be  unaltered,  the 
vessels  dilated,  and  many  of  them  filled  with  clot.  The 
colouring  appeared  to  be  due  to  blood- corpuscles  and  diffused 
colouring  matter  of  the  blood.  All  these  changes,  however, 
were  circumscribed,  and  might  easily  have  gone  on  to  complete 
restoration.  Much  more  extensive  alterations  were  found  on 
the  two  cauterized  surfaces  of  the  uterine  horns.  These  were 
so  completely  surrounded  by  folds  of  the  mesometrium  that 
they  could  not  be  seen  until  these  folds  had  been  dissected  off. 
At  only  one  spot  of  the  left  horn  near  the  cauterized  surface, 
an  opening  was  found  as  large  as  a  pin's  head,  which  opened 
into  the  dilated  cavity  of  the  horn.  About  two  centimetres 
distant  from  the  cauterized  surface,  the  mucous  membrane  and 
the  muscular  tissue  of  the  uterus  were  softened  and  gangrenous. 
Shreds  of  mucous  membrane  lay  in  the  cavity,  the  walls  of 
which  were  formed  merely  by  serous  membrane  and  the  adhe- 
rent mesometrium.  The  vessels,  even  to  the  smallest,  were 
completely  blocked  up  by  clot.  The  gangrenous  process  about 
the  cauterized  parts  appeared  to  be  due  to  the  extension  of 
clot  in  the  vessels  ;  but  all  was  encapsuled  by  the  mesometrium. 
No  pus  was  found  in  the  peritoneal  cavity,  not  even  near  the 
small  opening  which  communicated  with  the  uterine  cavity.  A 
successful  result  might  therefore  have  been  expected.  It  was 
obtained  in  the  two  following  cases. 

After  fourteen  days  the  cauterized  surfaces  of  the  central 
extremity  of  the  uterus,  as  well  as  those  of  both  horns,  were 
all  completely  encapsuled  by  mesometrial  folds.  The  central 
extremity  of  the  uterus  was  firmly  united  to  the  posterior  wall 
of  the  bladder  by  perfectly  organised  connective  tissue.  The 
cauterized  surface  of  the  right  horn  was  firmly  united  to  a  coil 
of  small  intestine. 

On  the  twenty-second  day  repair  was  found  to  be  complete. 
The  cauterized  surface  of  the  body  of  the  uterus  was  bound  to 
the  posterior  wall  of  the  bladder  by  a  fibrous  band.  The  cauterised 
surface  of  the  mesometrium  was  everywhere  smooth ;  nothing 
could  be  seen  to  show  that  a  piece  of  it  had  been  separated  by  the 
cautery  from  the  horns  of  the  uterus.  The  cauterised  spots 
on  the  uterus  were  smoothly  encapsuled,  and  the   only  traces 


3]  2  OBSERVATIONS  OF   MASLOWSKY   ON 

of  the  cautery  were  minute  remnants  of  animal  charcoal. 
These  fragments  of  charcoal  lay  in  a  firm  fibrillated  connective 
tissue  which  closed  the  uterine  cavity.  The  epithelium  of  the 
uterus  and  the  other  elements  of  the  uterine  wall  were  perfectly 
preserved. 

I  am  indebted  to  Dr.  Maslowsky,  of  St.  Petersburg,  for  two 
papers  which  he  kindly  sent  me,  one  from  the  ninth  volume  of 
Langenbeck's  '  Archiv,'  and  the  other  from  the  '  Berliner 
Klinische  Wochenschrift,'  which  contain  observations  corro- 
borative of  those  by  Spiegelberg  and  Waldeyer.  In  one 
successful  case  Dr.  Maslowsky  removed  both  ovaries,  treating 
the  right  pedicle  by  the  cautery  and  the  left  by  ligature,  re- 
turning both  into  the  peritoneal  cavity.  And  he  made  twelve 
experiments  on  rabbits,  dogs,  and  cats,  removing  the  horns  of 
the  uterus  and  the  omentum,  sometimes  by  the  galvanic 
cautery  and  sometimes  by  redhot  irons,  in  order  to  study  the 
process  of  capsulation  of  the  eschar  after  its  enclosure  within 
the  peritoneal  cavity,  and  the  share  which  the  white  blood- 
corpuscles  have  in  this  process.  As  these  corpuscles  take  up 
vermilion  from  the  blood,  Dr.  Maslowsky  injected  vermilion 
into  the  jugular  vein  at  different  periods  after  his  experiments, 
in  order  to  trace  the  corpuscles  in  any  product  of  inflammation. 

Microscopic  examination  of  the  animals  at  different  periods, 
from  fifteen  hours  to  seventy  days  after  operation,  proved  that 
the  eschar  on  the  uterine  horns  and  on  the  omentum  is  first 
covered  by  effused  fibrine,  and  is  afterward  united  by  mem- 
brane with  surrounding  organs.  '  The  fibrinous  exudation 
contains  many  round  cells  charged  with  vermilion,  and  some 
nucleoli  free  from  vermilion.  It  soon  loses  its  fine  fibrillar 
structure,  and  is  changed  into  a  finely  granular  mass.  The 
round  cells  with  vermilion  assume  an  oval  form,  and  then 
spindle-shaped  cells  are  also  seen  without  vermilion.  Some 
cells  contain  black  nucleoli  not  composed  of  vermilion ; 
afterwards  these  may  be  seen  between  the  fibres.  As  the 
capsulation  is  completed,  the  oval  cells  which  contain  ver- 
milion become  long  and  then  spindle-shaped.  And  I  have 
sometimes  observed  that  the  ends  of  two  spindle-shaped  cells 
coalesce,  and  at  once  form  a  fibre.  In  the  new-formed  mem- 
brane, capillaries  are  seen  as  soon  as  the  fourth  or  fifth  day, 
and  on  the  tenth  or  twelfth  the  vessels  may  be  easily  injected. 


STRUCTURAL   CHANGES   IN   CAUTERIZED   STUMPS  313 

I  have  also  seen  in  the  membrane  newly  formed  elastic  fibres 
and  scaly  epithelium,  both  free  from  vermilion.  The  false 
membranes  have  a  similar  structure.  It  is  therefore  an  un- 
deniable fact,  that  the  white  blood-corpuscles  participate  in  the 
formation  of  the  new  membrane  which  covers  the  eschar,  and 
unites  it  with  surrounding  organs.' 

The  eschar  made  by  the  galvanic  cautery  consists  of  animal 
charcoal  and  blood  pigment.  The  particles  of  animal  charcoal 
are  partly  lying  in  the  eschar,  and  are  partly  enclosed  in  sur- 
rounding connective  tissue.  When  red-hot  iron  is  used,  the 
eschar  also  contains  particles  of  oxide  of  iron,  some  of  which 
are  also  found  enclosed  by  the  elements  of  connective  tissue. 
It  is  proved  that  the  black  specks  are  really  iron  by  the  ordi- 
nary chemical  reactions.  The  mucous  membrane  of  the  uterus 
near  the  cauterized  part  was  suppurating,  and  the  pus-corpus- 
cles contained  vermilion. 

Dr.  Maslowsky  also  made  a  number  of  observations  on  the 
mesentery  and  mesometrium  of  frogs  and  rabbits,  in  order  to 
ascertain  the  precise  changes  which  the  vessels  themselves, 
and  the  blood  circulating  in  them,  undergo  after  the  application 
of  the  cautery.  From  twelve  to  twenty-four  hours  before  ex- 
amination vermilion  was  injected  into  the  jugular  vein.  The 
frogs  were  immobilised  by  woorara,  the  rabbits  narcotised  by 
opium.  The  results  of  the  microscopical  observations  are  as 
follows : — 

'  a.  The  end  of  closed  arteries  is  contracted  immediately  at 
the  cauterized  part,  but  at  some  distance  from  it  the  artery  is 
dilated.  The  canal  of  the  veins  is  affected  exactly  in  the 
reverse  manner. 

'  b.  The  blood  in  the  vessels  contains  black  particles  from 
the  heated  iron,  and  separates  itself  distinctly  into  a  layer  of 
white  blood-corpuscles,  which  are  near  the  cauterized  spot,  and 
a  layer  of  red  blood  corpuscles,  which  are  further  away. 

'  c.  In  the  closed  arteries  after  two  days  the  movement  of 
the  column  of  blood  is  maintained.  A  part  of  the  blood,  with 
the  black  particles  of  the  cauterized  artery  mixed  in  it,  reaches 
back  towards  the  trunk  of  the  vessel.  The  movement  of  the 
blood  in  cauterized  veins  is  only  kept  up  for  a  very  short  time. 
There  is  complete  stagnation,  not  only  in  the  cauterized  vein 
itself,  but  it  extends  further  up  to  the  junction  with  larger  veins. 


314  CAUTERIZATION   OF   TISSUES 

*  d.  The  black  particles  are  taken  up  by  the  white  blood- 
corpuscles.  This  can  be  seen  most  distinctly  in  the  vessels 
where  stagnation  of  the  blood  is  not  complete. 

'  e.  The  migration  of  white  blood-corpuscles,  partly  contain- 
ing vermilion  and  partly  black  particles,  begins  twenty,  thirty, 
or  sixty  minutes  after  cauterization.  They  are  first  seen  in  the 
veins  into  which  the  cauterized  vein  opens  ;  afterwards  in  the 
veins  near  the  cauterized  part.  Very  few  white  corpuscles 
migrate  from  the  arteries.  In  frogs,  as  the  mesentery  is  very 
broad  and  transparent,  this  migration  can  be  observed  for  three 
days  ;  in  rabbits  only  for  six  or  eight  hours. 

'  Similar  changes  in  the  vessels  and  migration  of  white 
blood-corpuscles  I  have  also  observed  after  ligature  of  mesen- 
teric vessels,  and  after  burning  away  part  of  the  tongue  in  the 
frog.  When  entire  portions  of  mesentery  are  burnt  away,  the 
same  alterations  occur,  but  to  a  much  greater  distance. 

*  A  hot  iron,  shaped  like  a  bird's  bill,  so  as  to  enter  for  some 
distance  into  a  vessel,  was  used  in  three  cases,  and  I  observed 
a  migration  of  white  blood-corpuscles,  charged  with  black  par- 
ticles, which  chemical  reaction  proved  to  consist  of  oxide  of  iron. 

'  It  is  therefore  certain  that  particles  of  iron  from  the  iron 
cautery  may  be  transmitted  with  the  white  blood-corpuscles 
into  different  tissues.' 

The  value  of  these  observations  is  unquestionable  ;  but  they 
did  not  lead  me  to  look  upon  either  the  cautery  or  the  ligature, 
or  any  intra-peritoneal  method  of  dealing  with  the  pedicle  of 
an  ovarian  tumour,  as  equal,  far  less  as  superior,  to  the  clamp, 
or  to  any  other  extra-peritoneal  method.  And  for  several  years 
after  publishing  all  this,  the  more  I  was  driven  by  the 
peculiarities  of  any  case,  or  encouraged  by  the  reported  suc- 
cesses of  others,  or  guided  by  the  desire  to  avoid  certain  obvious 
and  unavoidable  disadvantages  of  extra-peritoneal  methods  of 
dealing  with  the  pedicle,  to  resort  to  cautery  or  ligature — the 
less  was  I  satisfied  with  the  results  of  those  methods,  the  more 
reluctant  I  was  to  employ  them,  and  the  greater  was  my  con- 
fidence in  the  clamp  and  the  principle  of  the  extra -peritoneal 
method. 

In  some  respects  the  experiments  are  satisfactory,  as  they 
tell  us  what  really  does  take  place  when  a  ligature  or  an  eschar 
is  shut  up  in  the  peritoneal  cavity  ;  and  they  teach  us  that  we 


CONDITION   OF  THE   STUMP   AFTER   LIGATURE  315 

may  resort  to  the  cautery  or  the  ligature,  not  in  nearly  complete 
ignorance  as  to  what  we  may  expect  afterwards,  but  with  a 
pretty  accurate  idea  of  the  process  of  repair  and  of  the  dangers 
which  may  attend  this  process. 

Mr.  Doran,  in  two  valuable  papers  in  the  thirteenth  and 
fourteenth  volumes  of  the  '  St.  Bartholomew's  Hospital  Eeports,' 
gives  the  results  of  his  own  observations  of  ten  cases  where  he 
examined  the  ligature  and  pedicle  at  various  periods  after  ovari- 
otomy ;  all  proving  that  the  tied  or  strangulated  stump  is  not 
killed,  but  that  'a  communication  between  the  distal  and 
proximal  parts  of  the  stump  is  established  by  inflammatory 
plastic  effusion,  and  the  ligature  is  unravelled  by  granulation- 
cells  insinuating  themselves  between  its  fibres.'  He  also  shows 
that  the  distal  part  of  the  stump  may  soon  form  an  intimate 
adhesion  with  the  neighbouring  broad  ligament.  Mr.  Thornton 
('Med.  Times,'  June  1880)  puts  the  same  conclusion  in  these 
words : — 

'The  ligature  buries  itself  in  the  peritoneal  coat  of  the 
pedicle,  and  vascular  connexions  are  rapidly  established  between 
the  parts  adhering  over  it.  Lymph  is  thrown  out  over  the  end 
of  the  stump  and  over  the  ligatures  ;  in  this  new  vessels  form. 
The  stump  adheres  to  some  neighbouring  surface,  and  from  that 
derives  its  main  blood-supply.  In  either  case  the  passage  of 
blood  through  the  capillaries  under  the  ligature  is  an  important 
aid.  By  whichever  method  the  nourishment  of  the  stump  is 
carried  on,  the  strands  of  the  ligature  are  separated  by  ingrowth 
of  new  cells,  and  it  is  soon  absorbed  and  disappears.  Some- 
times the  knot  (or  the  whole  ligature,  if  very  thick  silk  is  used) 
becomes  encapsuled,  but  complete  disappearance  is  the  rule. 
It  will  be  obvious  that  the  least  favourable  method  is  that  in 
which  the  cut  surface  of  the  stump  adheres  to  some  neighbour- 
ing part ;  because  if  it  be  to  intestine  it  may  cause  a  kink  and 
direct  obstruction,  and  if  it  be  to  some  other  part  it  may  form 
a  bridge,  under  which  a  coil  of  intestine  may  become  adherent 
or  strangulated,  and  thence  may  follow  indirect  obstruction.' 

And  it  must  not  be  forgotten  that  even  in  healthy  dogs 
and  rabbits  where  the  ligature  or  the  cautery  was  considered 
by  the  German  experimenters  to  have  been  most  successful,  we 
have  seen  that  adhesion  of  the  tied  or  cauterized  part  to  the 
bladder,  to  intestine,  and  to  neighbouring  folds  of  peritoneum, 


316  OBJECTIONS   MADE   TO    CLAMP   TREATMENT 

has  been  the  rule,  just  as  in  cases  which  I  have  placed  upon 
record  where  adhesion  of  the  tied  or  cauterized  pedicle  to  intes- 
tines has  led  to  fatal  strangulation.  Even  if  not  fatal,  such 
adhesions  are  more  likely  to  lead  to  obstruction  of  intestine 
more  or  less  serious  and  prolonged,  and  to  be  permanently 
injurious,  than  the  mere  adhesion  of  a  pedicle  to  the  abdominal 
wall. 

Those  who  exclusively  follow  the  intra-peritoneal  method, 
and  either  use  the  cautery  or  return  the  ligature  and  close  the 
wound,  appear  to  have  been  influenced  by  objections  to  the 
extra-peritoneal  method  which  seem  to  me  to  be  either 
groundless  or  trivial.  When  the  pedicle  is  held  outside  the 
wound  by  a  clamp  or  in  any  other  way,  the  pull  upon  the 
uterus  or  broad  ligament  is  said  to  be  very  painful ;  but  I  have 
seen  a  good  deal  of  pull  with  very  little  pain,  and  much  more 
severe  pain  in  cases  where  the  ligature  was  used  than  I  ever 
saw  in  clamp  cases.  So  with  sickness  :  I  have  seen  as  much  or 
more  after  the  ligature  or  cautery,  as  I  ever  saw  after  the 
clamp.  It  is  said  to  set  up  fetid  discharge  and  poison  the 
wound  or  the  patient ;  and  so  it  does  if  proper  care  be  not 
taken.  But  if  the  strangulated  part  of  the  pedicle  which 
projects  beyond  the  clamp  be  well  saturated  with  perchloride 
of  iron,  the  slough  is  tanned ;  it  becomes  as  hard  and  dry  as  a 
piece  of  leather,  and  there  is  an  end  to  that  objection.  It  is 
said  to  cause  suppuration  about  the  wound  ;  but  this,  again,  I 
have  seen  both  after  the  ligature  and  cautery.  I  never  saw 
more  profuse  suppuration  of  the  stitches  than  in  one  case  where 
I  divided  the  pedicle  with  the  ecraseur,  and  closed  the  wound 
with  platinum  wire  sutures.  Then,  after  the  wound  is  closed, 
it  is  said  to  lead  to  a  reopening  each  month,  and  an  escape  of 
some  menstrual  fluid.  And  this  is  true  in  some — perhaps  in 
nearly  a  third — of  the  cases.  But  if  the  patient  be  prepared 
for  it,  it  is  not  of  the  slightest  consequence.  The  Fallopian 
tube  almost  always  contracts  completely  after  a  few  months, 
and  there  is  no  further  escape.  I  can  only  recollect  two  cases 
where  it  has  continued  up  to  the  date  of  the  last  report  from 
the  patient,  and  then  it  caused  but  slight  inconvenience.  If 
menstrual  fluid  can  escape  through  the  partially  closed  Fallopian 
tube  fixed  in  the  cicatrized  wound,  so  it  may  escape  if  the  tube 
be  left  within  the  peritoneal  cavity,  and  the  result  may  be  a 


TREATMENT   OF   PEDICLE   ECLECTIC  317 

fatal  hematocele.  I  have  known  this  to  occur  in  two  cases 
where  the  ligature  was  used  and  cut  off  short ;  and  I  believe  it 
to  be  one  of  the  strongest  objections  to  this  method,  or  to  any 
intra-peritoneal  method  of  dealing  with  the  pedicle.  I  can 
recall  at  least  six  patients  who,  at  various  periods  after  recovery 
from  intra-peritoneal  treatment  of  the  pedicle,  have  suffered 
from  conditions  which  I  could  only  explain  on  the  supposition 
that  the  end  of  the  Fallopian  tube  remained  open,  and  that  a 
hematocele  of  more  or  less  serious  importance  had  formed  at 
successive  menstrual  periods.  Fortunately,  I  have  never  had 
an  opportunity  of  testing  the  accuracy  of  this  diagnosis  by  post- 
mortem examination.  As  to  any  fancied  impediment  to  the 
increase  of  the  uterus  in  pregnancy,  and  to  its  contraction 
during  labour,  from  the  adhesion  of  the  tube  to  the  cicatrix, 
cases  will  be  found,  when  we  come  to  consider  the  subsequent 
history  of  patients  who  have  had  children  after  ovariotomy, 
amply  proving  that,  neither  during  pregnancy  nor  labour,  has 
any  suffering  or  difficulty  been  attributed  by  them  to  any  such 
consequences  of  the  use  of  the  clamp.  Many  women  have  had 
one  child,  some  two,  some  three,  and  others  as  many  as  six  or 
seven  children  ;  and  in  no  case  has  any  unusual  suffering  been 
referred  to  the  adhesion  of  the  pedicle  to  the  abdominal  wall. 
One  real  objection  to  the  clamp  is  that  it  may  possibly  pull  on 
intestine,  or  a  tense  pedicle  may  strangulate  intestine  (and  I 
have  seen  one  such  case).  But  this  objection  is  of  little  weight 
if  the  use  of  the  clamp  be  restricted  to  cases  where  the  pedicle 
is  so  long  that  there  is  not  much  drag  on  the  clamp.  Where, 
however,  we  have  a  broad,  thick,  short  pedicle,  or  a  broad  con- 
nection between  uterus  and  cyst  rather  than  a  distinct  pedicle, 
we  must  have  something  different  from  the  clamp.  And  we 
have  the  choice  between  one  or  other  of  the  intra-peritoneal 
methods. 

But  no  surgeon  who  has  had  much  experience  of  ovari- 
otomy would  bind  himself  to  adopt  in  all  cases  either  the  extra- 
peritoneal or  the  intra-peritoneal  method,  or  any  of  the  modifi- 
cations by  which  either  principle  is  carried  out  in  practice. 
Every  surgeon  should  go  to  an  operation  prepared  to  carry  out 
the  particular  method  which  appears  to  be  best  adapted  to  the 
peculiar  circumstances  of  the  case  which  present  themselves  as 
he  proceeds.     But  since  the  great  success  which  has  attended 


318 


APPLICATION   OF  LIGATURE 


the  combinations  of  antiseptic  ovariotomy  and  the  complete 
intra-peritoneal  treatment  of  the  pedicle,  the  extra-peritoneal 
method  may  be  considered  as  almost  abandoned,  and  we  have 
to  choose  between  the  ligature  and  the  cautery. 

In  ligaturing  the  pedicle  of  an  ovarian  tumour,  it  is  never 
safe  to  trust  to  a  ligature  which  does  not  transfix  the  pedicle, 
unless  this  be  very  long  and  slender.  Many  cases  are  on  record 
where,  after  cutting  away  the  tumour,  a  simple  encircling  liga- 
ture has  slipped  off,  and  dangerous  or  fatal  bleeding  has  fol- 
lowed. It  should  be  a  rule,  therefore,  always  to  transfix  a. 
pedicle,  and,  according  to  its  size,  to  tie  in  two  or  more  portions, 


before  the  cyst  is  cut  away.  A  long  ordinary  needle  double- 
threaded  may  be  used,  or  a  long  blunt-pointed  needle  on  a  handle, 
straight  or  curved.  The  latter  is  safer  and  more  convenient  if 
the  pedicle  cannot  easily  be  brought  well  outside  the  abdomen. 
Both  threads  having  been  carried  through  the  same  puncture, 
one  is  tied  above  and  one  below  the  Fallopian  tube,  as  shown  in 
the  sketch,  a  second  turn  having  been  given  to  the  first  loop  to 
prevent  slipping  when  the  second  turn  securing  the  knot  is 
made.  For  additional  security  a  separate  ligature  may  be  tied 
between  the  two  first  passed  and  the  uterus.  Mr.  Bryant  and 
some  other  operators  think  it  important  that  one  loop  should 
be  laced  within  the  other,  as  shown  in  the  lower  sketch.     But 


ENDS   OF  LIGATURES  319 

I  rather  avoid  this,  as  it  is  possible  that  by  so  tying  the  second 
knot  the  first  may  be  loosened.  Supposing  a  clamp  or  pressure- 
forceps  to  have  been  first  applied,  the  cyst  cut  away,  and  the 
pedicle  then  transfixed  and  tied  between  the  forceps  and  the 
uterus,  the  clamp  must  be  loosened  or  the  forceps  removed 
before  the  ligatures  are  tightened.  If  this  is  not  done,  the 
knot  cannot  be  tied  so  tight  as  to  be  secure  after  the  clamp  is 
removed.  As  the  clamp  is  taken  off,  the  tissues  compressed  by 
it  -retract,  and  are  apt  to  slip  from  under  the  ligature.  This 
can  only  be  avoided  by  tightening  the  ligatures  simultaneously 
with  the  loosening  of  the  clamp  or  removal  of  the  forceps. 
Mr.  Doran's  observations  lead  him  to  the  conclusion  that  *  it  is 
much  more  dangerous  to  draw  the  ligatures  a  little  too  firmly, 
than  to  leave  them  somewhat  looser  than  is  strictly  advisable  ; ' 
and  Mr.  Thornton  considers  the  presence  of  blood-clot  on  the 
cut  surface  of  the  stump  *  as  the  perfect  condition  to  aim  at  in 
the  treatment  of  the  ovarian  pedicle  by  ligature.  This  cap  of 
blood-clot  shows  that  the  ligatures,  while  tight  enough  to 
prevent  serious  hemorrhage,  were  not  so  tight  as  to  cut  off  all 
supply  from  the  distal  portion  of  the  stump.'  I  differ  entirely 
both  from  Mr.  Doran  and  Mr.  Thornton,  and  fearing  that  a  loose 
ligature  will  become  looser  as  the  included  tissue  shrinks,  that 
bleeding  would  be  probable,  and  that  unless  a  ligature  sinks 
deeply  into,  or  forms  a  deep  groove  in  the  pedicle,  the  surfaces 
of  peritoneum  on  either  side  of  it  are  less  likely  to  unite,  cover 
up  the  silk,  and  maintain  the  vitality  of  the  stump,  I  always 
tie  the  ligatures  as  tightly  as  I  can. 

If  it  be  desired  only  to  tie  the  vessels,  it  may  be  done  by 
feeling  the  arteries,  and  carrying  a  ligature  round  them  through 
the  pedicle  before  the  cyst  is  cut  away ;  or,  after  the  applica- 
tion of  forceps  and  removal  of  the  cyst,  holding  the  pedicle 
carefully  as  the  forceps  are  removed,  and  tying  any  vessel  which 
bleeds.  The  great  objection  to  this  plan  is,  that  there  is  often 
much  loose  cellular  tissue,  rich  in  small  veins,  which  go  on 
oozing  after  all  the  larger  vessels  have  been  tied.  Whichever 
may  be  the  plan  preferred,  the  important  question  arises: 
Shall  the  ends  of  the  ligatures  be  cut  off,  and  the  wound  closed? 
or  shall  they  be  left  hanging  out  through  a  part  of  the  wound, 
purposely  left  open  for  their  passage,  and  that  of  the  slough 
they  embrace  when  it  separates  ?     Dr.  Clay,  of  Manchester, 


320  ENDS   OF   LIGATURES,    HOW    DEALT   WITH 

advocated  this  latter  practice.  In  its  favour,  it  may  be  said, 
that  it  is  a  method  applicable  in  all  cases ;  that  it  secures  an 
outlet,  for  serum  from  the  peritoneal  cavity  ;  and  that,  after  the 
separation  of  the  ligature  and  slough,  no  foreign  body  is  left 
within  the  patient.  But  it  seems  to  me  that  the  ligature- 
threads  act  as  a  sort  of  seton  in  the  peritoneal  cavity,  excite 
the  formation  of  the  serum  for  which  they  are  said  to  provide 
the  outlet,  and  counteract  antiseptic  precautions.  Having  tried 
both  methods,  the  results  wouM  lead  me  to  cut  off  the  ends 
whenever  the  patient  is  in  pretty  good  condition,  and  sthenic 
peritonitis  with  effusion  of  lymph  may  be  expected ;  and  if  low 
diffuse  peritonitis  and  effusion  of  serum  may  be  feared,  then  it 
would  be  better  to  secure  a  drain  through  the  wound  for  the 
serum  by  a  glass  drainage  tube  than  by  the  ends  of  a  ligature. 
I  have  treated  cases  successfully  in  this  manner,  but  the  results 
have  not  been  so  satisfactory  as  to  induce  me  to  use  it,  unless 
compelled  to  do  so  by  the  circumstances  of  the  case.  On  this 
question  of  drainage  I  shall  have  more  to  say  hereafter.  One 
objection  is,  that  even  if  the  patient  recover,  there  is  a  great 
liability  to  ventral  hernia.  The  cicatrix  remains  weak  at  the 
spot  where  the  tube  or  ligatures  passed  out,  and  it  yields  before 
the  pressure  outwards  of  the  viscera.  I  have  seen  this  in  nearly 
every  case  where  I  adopted  this  plan  ;  in  several  where  it 
followed  the  clamp ;  in  some,  but  in  smaller  proportion,  where 
the  complete  intra-peritoneal  method  was  practised,  and  I  have 
come  to  the  conclusion  that  if  we  use  one  or  more  ligatures,  it 
is  better  to  cut  off  the  ends  short,  and  close  up  the  wound  com- 
pletely. Wire  has  been  used  for  this  purpose ;  but  it  seems  an 
irrational  practice.  Silk,  if  pure,  is  an  animal  substance  ;  and 
experiment  proves  that  it  may  be  absorbed.  Wire  cannot  be 
absorbed,  and  must  be  more  or  less  of  a  mechanical  irritant. 
I  tried  wire  on  one  side  and  silk  on  the  other  side  of  a  sheep 
on  which  Professor  Gamgee  operated  for  me  at  the  Albert 
Veterinary  College,  and  the  superiority  of  the  silk  was  manifest. 
What  we  have  to  look  to  is  the  effect  on  the  tissues  strangu- 
lated, rather  than  the  material  by  which  the  strangulation  is 
effected.  Catgut  has  been  used,  but  I  know  of  nothing  to  show 
that  it  is  superior  to  carbolized  silk.  Professor  Billroth  thinks 
it  necessary  to  boil  the  silk  in  a  5  per  cent,  solution  of  carbolic 
acid.  I  have  been  content  with  simply  soaking  the  silk  in  the 
solution. 


ACUPRESSURE 


321 


Acupressure  was  once  applied  successfully  by  Sir  James 
Simpson.  He  secured  the  pedicle  by  passing  a  long  needle 
through  the  abdominal  wall,  across  the  pedicle,  and  out  again. 
The  pedicle  was  thus  compressed  by  the  needle,  as  here  shown, 
on  the  outside  of  the  abdominal  wall.     The  head  and  point  of 


the  needle  are  seen  on  the  surface  of  the  abdomen,  compressing 
the  pedicle  in  the  left  iliac  region.  Another  pin,  to  the  right 
of  the  incision,  is  supposed  to  compress  vessels  opened  during 
the  separation  of  adhesions.     The  next  cut  is  a  diagram  of  an 


impossible  view  of  the  inner  surface  of  the  abdominal  wall, 
with  one  acupressure  needle  crossing  a  wounded  vessel  near  the 
incision,  while  a  larger  needle,  at  6,  passes  across  the  pedicle  of 
the  ovarian  tumour  which  has  been  removed.  The  uterus  is 
shown  at  d,  and  the  rectum  at  e. 

Sir  William  Fergusson  once  tried  this  plan,  but  was  obliged 
to  resort  to  the  ligature.    I  have  never  tried  it  myself,  though  I 

Y 


322  THE   ECRASEUR 

have  more  than  once  found  acupressure  useful  in  stopping 
bleeding  from  vessels  torn  in  separating  adhesions. 

The  ecraseur  has  been  used  for  the  compression  and  crush- 
ing of  the  pedicle  and  the  final  separation  of  the  tumour ;  after 
which  the  pedicle  is  dropped  into  the  abdominal  cavity  and  the 
wound  closed.  Grave  objections,  however,  against  this  prac- 
tice are  the  possibility  of  internal  haemorrhage  and  its  accom- 
panying dangers,  and  the  difficulty  of  finding  and  securing  the 
bleeding  pedicle  in  the  depth  of  the  abdominal  cavity  after 
having  reopened  the  wound.  This  would  be  especially  diffi- 
cult if  haemorrhage  occurred  after  some  lapse  of  time.  I  once 
used  the  ecraseur  and  successfully ;  but  I  have  not  ventured 
on  it  again,  for  fear  that  it  might  prove  untrustworthy  and 
dangerous  internal  bleeding  occur.  This  danger  might  be 
prevented  by  tying  a  strong  ligature  below  the  ecraseur  chain, 
before  separating  the  cyst  and  dropping  the  pedicle  into  the 
abdominal  cavity.  But  then  it  would  be  only  a  modification 
of  the  former  methods  of  ligatures,  and  open  to  the  same 
objections. 

The  cautery  alone  would  almost  certainly  fail  to  stop  such 
large  vessels  as  are  frequently  met  with  in  a  pedicle.  So  might 
the  ecraseur  alone,  or  the  crushing  which  precedes  the  division 
by  the  ecraseur.  But  the  combination  of  crushing  and  the 
cautery  is  certainly  efficacious  in  a  considerable  proportion  of 
cases.  Mr.  Clay,  of  Birmingham,  introduced  the  practice  and 
carried  it  out  by  his  adhesion  clamp  and  hot  irons,  both  for 
dividing  adhesions  and  omentum.  The  practice  was  extended 
to  the  pedicle  by  Mr.  Baker  Brown,  and  has  since  been  used 
chiefly  by  Dr.  Keith.  It  is  claimed  for  it  that  in  most  cases 
it  effectually  stops  haemorrhage  during  the  operation  and  pre- 
vents it  afterwards,  that  it  leaves  only  a  very  thin  layer  of 
burnt  tissue  at  the  end,  and  is  followed  only  by  the  changes 
which  have  been  described  in  a  former  page.  This  method  is 
of  most  value  in  cases  when  the  pedicle  is  broad,  thick,  and 
short ;  it  does  not  answer  well  when  large  vessels  ramify  in  a 
thin  membranous  pedicle.  Notwithstanding  the  great  advan- 
tage which  deservedly  recommends  the  cautery,  its  use  is  some- 
times attended  by  serious  drawbacks.  Vessels  not  unfrequently 
bleed  on  opening  the  blades  of  the  clamp,  and  a  repetition  of 
the  whole  tedious  proceeding,  or  the  use  of  ligatures,  is  neces- 


COMBINED   CRUSHING   AND   CAUTERIZATION  323 

sary  before  the  pedicle  can  be  returned  into  the  abdomen  with 
safety. 

The  instrument  used  for  securing  and  compressing  the 
pedicle  is  Mr.  Clay's  (of  Birmingham)  adhesion  clamp,  modified 
first  by  Mr.  B.  Brown,  afterwards  by  me  and  by  others.  Having 
adjusted  the  clamp  and  tightly  compressed  the  pedicle  between 
its  blades,  which  are  kept  closed  by  means  of  a  screw,  the 
tumour  is  cut  off  a  short  distance  above  the  clamp.  The  pro- 
jecting portion  of  the  pedicle  is  dried,  and  held  with  a  forceps 
during  the  application  of  the  cautery.  In  order  to  protect  the 
surrounding  parts  from  the  hot  iron,  towels  or  flannel,  placed 
between  the  clamp  and  the  abdomen,  were  first  employed ;  but 
they  often  proved  insufficient.  I  have  used  two  shields  made 
of  talc  (neutral  silicate  of  alumina,  a  perfect  non-conductor  of 
heat),  which,  when  placed  around  the  pedicle,  will  protect  the 
skin  and  any  part  likely  to  be  injured.  The  cautery-irons, 
which  are  wedge-shaped  with  a  blunt  edge,  should  be  heated 
to  a  dull  red  heat,  and  pressed  slowly  and  firmly  across  the 
protruding  portion  of  the  pedicle,  until  this  is  burnt  off  clean 
down  to  the  surface  of  the  clamp,  as  shown  in  the  drawing  on 
page  280,  before  the  tumour  has  been  cut  away.  This  done, 
the  blades  are  cautiously  opened,  the  operator  and  his  assistants 
being  prepared  to  seize  the  pedicle,  and  prevent  it  from  slipping 
into  the  abdominal  cavity,  in  case  any  bleeding  should  occur. 
Having  convinced  himself  that  there  is  no  bleeding,  the  opera- 
tor gently  disengages  the  pedicle  from  the  blade,  and  allows  it 
to  drop  into  the  abdominal  cavity. 

Dr.  Maslowsky  uses  a  long  pair  of  forceps  which  compress 
the  pedicle  at  only  a  few  points,  yet  hold  it  securely — and  these 
are  applied  before  the  clamp  is  removed.  Then  if  any  vessel 
bleeds,  it  can  be  touched  by  a  pointed  cautery.  The  late  Dr. 
Wright  devised  an  ingenious  clamp,  by  which,  before  opening 
the  blades,  a  succession  of  steel  bars  can  be  lifted  by  means 
of  screws,  and  the  pedicle  thus  partially  exposed,  in  order  to 
discover  and  to  secure  any  bleeding  vessel  without  disengaging 
the  whole  pedicle  from  the  grasp  of  the  clamp  after  the  appli- 
cation of  the  cautery.  Mr.  Clover  introduced  a  very  useful 
cautery  of  pure  silver,  heated  by  burning  spirit.  Mr.  Bruce 
invented  a  gas  cautery.  The  electric  cautery  and  Paquelin's 
cautery  have  also  been  used. 

v  2 


324 


THE    CLAMP 


Although  the  clamp  is  now  almost  disused,  it  is  so  simple, 
safe,  and  rapid  a  mode  of  dealing  with  the  pedicle  for  an 
inexperienced  operator  that  it  is  almost  necessary  to  repeat  the 
directions  for  its  use  given  as  follows  in  my  edition  of  1872. 

The  next  drawing,  by  Dr.  Junker,  was  made  when  he  was 
watching  me  actually  applying  the  form  of  clamp  which  I  last 


used.     The  tumour  was  held  up  by  one  of  the  assistants,  the 
clamp  passed  round  the  pedicle,  and  my  right  hand  is  shown 

! 


pressing  the  blades  of  the  clamp  together  by  the  forceps. 
This  compression  should  be  very  firm,  and  the  forceps  should 
be  held,  while  the  screw  which  fixes  the  clamp  is  tightened 


MODE    OF   APPLICATION  325 

by  the  left  hand.  After  the  tumour  has  been  cut  away,  it  is 
sometimes  necessary  to  tighten  the  clamp  still  further,  or  to 
tighten  the  screw.  The  assistant  keeps  the  abdominal  wall 
closed  around  the  pedicle,  as  shown  in  the  second  drawing  on 
the  previous  page,  also  from  the  life ;  while  the  surgeon, 
holding  the  clamp-forceps  with  his  left  hand,  fastens  the  screw 
with  his  right,  assisted  by  the  needle  holder. 

It  would  seem  unnecessary  to  add  that  the  surgeon  should 
be  extremely  careful  not  to  enclose  anything  but  the  pedicle  in 
the  clamp,  but  the  fact  that  cases  are  on  record  where  a  portion 
of  the  bladder  has  been  squeezed,  and  where  one  ureter  has 
been  strangulated,  and  that  I  have  myself  seen  a  strip  of 
omentum  several  times,  and  a  coil  of  intestine  once,  very 
narrowly  escape  constriction,  shows  that  the  caution  is  not 
uncalled  for. 

After  the  tumour  has  been  cut  away  and  the  screw  securely 
tightened,  the  edges  of  the  wound  are  held  in  contact  round  the 
pedicle,  which,  with  the  clamp,  should  be  brought  as  near  to 
the  lower  end  of  the  incision  as  can  be  done  without  traction, 


and  the  edges  of  the  wound  are  brought  in  contact  around  it,  as 
shown  in  the  above  drawing. 

Any  superfluous  portion  of  the  pedicle  protruding  beyond 


326 


RESULTS   OF   VARIOUS   MODES 


the  clamp  is  cut  off,  but  not  quite  close  to  the  clamp,  for  this 
would  lead  to  the  danger  of  the  pedicle  as  it  shrank  sinking  or 
being  drawn  inwards.  It  is  as  well  to  leave  about  a  quarter 
of  an  inch  protruding  beyond  the  clamp,  and  this  should  be 
touched  with  solid  perchloride  of  iron,  by  which  the  tissue  is 
tanned  until  it  becomes  quite  dry  and  leathery,  and  is  pre- 
served from  putrid  decomposition.  The  following  tables  show 
the  results  of  my  own  trials  of  various  modes  of  dealing  with 
the  pedicle  in  1,000  cases. 


Various  Modes  of  Dealing  with  the  Pedicle  and 

Attachments  op  the  Tumour. 

First  Scries  of  500. 


Cases 

Recoveries- 

Deaths 

Mortality 
per  cent. 

Clamp        ...... 

Pin  and  ligature  acting  as  clamp 
Clamp  and  ligature   .... 

Ligature  returned      .... 

Ligature  brought  out 

Cautery 

Cautery  and  ligature 

Ecraseur 

349 
15 
34 
57 
14 
16 
14 
1 

280 
10 
23 
29 

6 
14 
10 

1 

69 

5 

11 

28 
8 
2 
4 
0 

19-77 
33-33 
32-35 
49-12 
57-14 
12-5 
28-57 
0 

500 

373 

127 

25-4 

Various  Modes  of  Dealing  with  the  Pedicle  and 

Attachments  of  the  Tumour. 

Cases  501  to  1,000. 


Cases 

Recoveries 

Deaths 

Mortality 
per  cent. 

Clamp         ...... 

274 

217 

57 

20-8 

Pin  and  ligature  acting  as  clamp 

2 

1 

1 

50 

Clamp  and  ligature  .... 

15 

11 

4 

26-66 

Ligature  returned 

203 

162 

41 

20-19 

Ligature  brought  out 

— 

— 

— 

— 

Cautery      .... 

— 

— 

— 

— 

Cautery  and  ligature 

— 

— 

— 

— 

Ecraseur  and  pin 

1 

1 

0 

0 

Forceps  and  ligature 

1 

0 

1 

100 

No  ligature — enucleation  . 

3 

3 

0 

0 

Cyst  wall  sewed  to  abdominal  wall  . 

1 

0 

1 

100 

500 

395 

105 

21 

OF    TKEATING    THE   PEDICLE 


327 


Various  Modes  of  Dealing  with  the  Pedicle  and 
Attachments  of  the  Tumour. 

The  whole  Series  of  1,000. 


Cases 

Recoverief 

Deaths 

Mortality 
per  cent. 

Clamp 

623 

497 

126 

20-22 

Pin  and  ligature  acting  as  clamp 

17 

11 

6 

35-23 

Clamp  and  ligature   .... 

49 

34 

15 

30-61 

Ligature  returned 

260 

191 

69 

26-53 

Ligature  brought  out 

14 

6 

8 

57-14 

Cautery 

16 

14 

2 

12-5 

Cautery  and  ligature 

14 

10 

4 

28-57 

Ecraseur  and  pin 

2 

2 

0 

0 

Forceps  and  ligature 

1 

0 

1 

100 

No  ligature — enucleation 

3 

3 

0 

0 

Cyst  wall  sewed  to  abdominal  wall  . 

1 

0 

1 

100 

1,000 

768 

232 

23-2 

Whether  the  clamp,  the  cautery,  or  the  ligature  be  used, 
when  dividing  the  pedicle  and  separating  the  cyst,  the  utmost 
care  must  be  taken  to  prevent  any  of  the  contents  of  the  cyst 
entering  the  abdominal  cavity.  Should  this  have  happened 
notwithstanding  all  the  precautions  taken  to  avoid  it,  the  cavity 
must  be  carefully  sponged  and  cleaned  of  all  extraneous  sub- 
stance with  soft  sponges  wrung  out  of  warm  water. 

The  omentum,  the  mesentery,  and  the  situations  of  the 
adhesions  to  the  anterior  abdominal  wall  will  often  be  found 
the  seat  of  haemorrhage,  either  from  the  orifices  of  large  vessels 
or  from  capillary  oozing.  The  bleeding  must  be  stopped  by 
tying  the  vessels  with  ligatures,  the  ends  of  which  are  to  be 
cut  off  close  to  the  knot,  or  by  torsion,  or  by  the  pressure  of  a 
needle  passed  across. 

As  soon  as  the  pedicle  has  been  secured  and  the  tumour 
removed,  and  any  omental  or  other  vessels  injured  during  the 
separation  of  adhesions,  and  bleeding,  have  been  tied,  the  other 
ovary  should  be  examined.  It  is  easily  found  by  grasping  the 
fundus  of  the  uterus,  and  passing  the  hand  downwards  along 
the  tube  and  side  of  the  uterus.  If  the  ovary  is  healthy,  it  is 
found  to  be  of  about  the  normal  size  and  consistence.  Its 
surface  may  be  irregular  from  recently  matured  Graafian  fol- 
licles, but  these  need  not  lead  to  interference  unless  the  ovary 


328      EXAMINATION  OF  SECOND  OVARY  AND  UTERUS 

is  two  or  three  times  its  normal  size.  If  one  or  two  Graafian 
follicles  are  very  large,  they  may  be  punctured,  and  the  clot  they 
contain  squeezed  out.  If  the  ovary  is  hardened  or  so  enlarged 
that  disease  appears  likely  to  go  on,  it  should  be  removed. 
Occasionally  the  pedicle  has  been  long  enough,  especially  in 
cysts  of  considerable  size,  to  admit  of  the  application  of  a 
second  clamp ;  and  I  have  fixed  two  clamps  outside  the  ab- 
dominal wall  with  little  more  inconvenience  to  the  patient 
than  one.  In  other  cases  I  have  transfixed  the  pedicle  of  the 
second  tumour,  tied  it  in  two  or  more  portions,  brought  it 
outside,  and  tied  it  to  the  clamp  securing  the  first  pedicle. 
In  other  cases,  where  there  was  no  pedicle,  but  a  close  attach- 
ment of  the  ovarian  tumour  to  the  side  of  the  uterus,  after 
transfixing  the  attachment,  tying  it,  and  cutting  away  the 
tumour,  I  have  cut  off  the  ends  of  the  ligatures  short  and  left 
them.  In  one  case,  where  two  ovarian  cysts  had  burst,  the 
contents  had  escaped  into  the  peritoneal  cavity,  and  general 
chronic  peritonitis  had  followed,  both  pedicles  were  secured  in 
separate  clamps,  one  to  each  pedicle,  and  they  were  easily  kept 
above  the  united  wound.  The  patient  made  a  good  recovery. 
Eecently  I  have  always  tied  both  pedicles  with  silk,  cutting  off 
the  ends  short,  just  as  when  only  one  ovary  has  been  removed. 

Besides  examining  the  second  ovary,  the  state  of  the  uterus 
should  be  ascertained.  It  may  be  enlarged  by  pregnancy,  as 
described  in  Chapter  XIII.,  or  it  may  be  enlarged  by  fibroid 
growths  or  out-growths.  In  one  case,  after  completing  ovari- 
otomy, I  also  removed  a  fibroid  out-growth  from  the  fundus 
uteri.  This  patient  died,  and  I  think  she  would  have  recovered 
if  I  had  left  the  uterus  alone,  as  I  have  done  in  five  or  six  cases 
since,  where  the  size  of  the  growths  was  insignificant.  But 
when  they  have  been  large  enough  to  cause  much  inconvenience, 
I  have  removed  them  at  the  same  time  as  the  ovarian  tumour. 
Two  years  ago,  Case  979,  the  patient  recovered  after  removal  of 
a  uterine  tumour  nearly  as  large  as  the  ovarian,  and  this  year  I 
successfully  removed  a  dermoid  cyst  of  the  left  ovary,  and  a 
fibroid  outgrowth  from  the  right  side  of  the  uterus  at  the  one 
operation.  More  will  be  said  on  the  removal  of  uterine  tumours 
in  the  concluding  chapter  of  this  book. 

Before  proceeding  to  close  the  wound,  the  peritoneal  cavity 
must  be  thoroughly  cleansed  from  any  fluid  or  clot  which  it 


CLEANSING   THE   PERITONEAL   CAVITY  329 

may  contain.  A  good  deal  of  fluid  may  be  simply  pressed  out, 
or  scooped  out  as  it  were,  by  the  hand  of  the  operator ;  but 
complete  cleansing  can  only  be  effectually  attained  by  using 
many  clean,  soft  sponges  in  succession,  passing  them  well  down 
behind  and  in  front  of  the  uterus,  along  each  flank  in  front  of 
the  kidneys,  and  over  the  abdominal  wall  wherever  adhesions 
have  been  separated,  carefully  removing  any  clot  which  may 
be  seen  or  felt  among  the  coils  of  intestine  or  folds  of  omentum. 
When  I  began  to  insist  upon  the  importance  of  this  process, 
which  Dr.  Worms  described  as  la  toilette  du  peritoine,  other 
operators  said  that  it  was  unnecessary  or  injurious  ;  that  ovarian 
fluid  in  the  peritoneum  was  harmless ;  or  that  the  time  lost  in 
removing  it,  and  the  irritation  caused  by  the  sponging,  were 
greater  evils  than  a  little  fluid  or  blood  left  in  the  cavity.  Im- 
pressed by  these  objections,  I  was  in  one  case  less  careful  than 
usual  in  sponging  away  ovarian  fluid.  A  fatal  result  followed, 
and  I  at  once  published  the  case,  rather  as  a  warning  than  an 
example,  and  I  have  ever  since  been  extremely  careful  to  remove 
all  I  possibly  could  by  thorough  sponging,  and  have  been  well 
satisfied  with  the  general  results.  I  have  regretted  incomplete 
sponging,  never  that  I  had  been  too  careful.  And  it  is  very 
convenient  to  insert  a  large,  broad,  flat  piece  of  thin  sponge 
just  within  the  wound,  and  leave  it  all  the  time  that  the  sutures 
are  being  passed.  It  protects  the  intestines  and  peritoneal 
cavity  generally,  catches  any  drops  of  blood  which  may  follow 
the  passage  of  the  needles,  and  if  spray  be  used  protects  the 
cavity  from  the  cooling  effect  of  the  spray,  or  the  entrance  of 
carbolic  acid. 

The  next  step  will  be  to  close  the  wound.  In  my  early 
cases  I  did  this  by  passing  ordinary  or  gilded  hare-lip  pins 
through  the  whole  thickness  of  the  abdominal  wall  at  intervals 
of  an  inch.  Each  pin  perforated  the  skin  about  an  inch,  and 
the  peritoneum  about  half  an  inch,  from  the  incision  on  either 
side ;  so  that  when  the  two  opposed  surfaces  were  pressed  to- 
gether upon  the  pin,  two  layers  of  the  peritoneum  were  in  contact 
with  each  other.  But  I  soon  began  to  use  and  prefer  sutures 
to  pins,  and  tried  different  materials  for  this  purpose — hemp, 
twine,  silk,  silver  and  steel  wire,  telegraph  wire  coated  with 
gutta-percha,  and  strong  horse-hair.  After  repeated  compara- 
tive  trials  I  found  thin  strong  Chinese  silk  superior  to  the  other 


330  .       CLOSING   THE   WOUND 

materials.  For  the  last  three  years  I  have  soaked  the  silk  in 
a  5  per  cent,  solution  of  carbolic  acid  before  using  it.  Perhaps 
it  may  be  found  safer  to  boil  it  in  the  carbolized  solution. 

The  most  convenient  manner  of  applying  the  sutures  is  the 
following.  Silk  about  eighteen  inches  in  length  is  threaded 
at  each  end  on  a  strong  straight  needle.  Each  needle  is  intro- 
duced from  within  outwards,  through  the  peritoneum  and  the 
whole  thickness  of  the  abdominal  wall,  at  about  one-third  of 
an  inch  from  the  cut  edges  of  peritoneum  and  skin  on  either 
side — pinching  up  peritoneum  and  skin  together,  so  that  the 
silk  may  be  carried  through  both  without  perforation  of  the 
recti  muscles.  The  ends  of  the  sutures  are  held  by  the  assistant, 
who  draws  up  the  lips  of  the  wound  until  all  the  deep  sutures 
have  been  applied.  Then  the  lips  of  the  wound  are  held  apart 
again,  in  order  that  the  operator  may  convince  himself  that  no 
further  bleeding  has  taken  place  within  the  abdominal  cavity, 
which,  if  required,  has  to  be  sponged  again,  and  the  protecting 
sponge  removed.  This  done,  the  sutures  are  tied,  and  the 
ends  of  the  threads  cut  off.  If  the  abdominal  wall  is  very 
thick,  superficial  sutures  may  be  required  between  the  deep 
ones.  If  the  pedicle  has  been  secured  by  the  clamp,  a  suture 
should  be  passed  close  to  the  latter,  in  order  to  bring  the  lips 
of  the  wound  so  accurately  around  the  pedicle  that  the  peri- 
toneal cavity  is  perfectly  closed.  At  the  risk  of  being  tedious, 
I  repeat  that  the  including  of  the  peritoneum  within  the  stitches 
is  of  the  utmost  importance  for  the  success  of  the  operation. 
The  two  peritoneal  layers  adhere  together  very  rapidly.  At 
the  post-mortem  examination  of  patients  who  died  after  twenty- 
four  hours,  the  edges  of  the  peritoneal  incision  have  been  found 
firmly  united  by  first  intention.  Thus  pus  and  other  secretions 
from  the  wound  are  prevented  from  entering  the  peritoneal 
cavity,  adhesion  of  the  omentum  or  intestine  to  any  part  of  the 
inner  aspect  of  the  wound  not  covered  by  peritoneum  is  avoided, 
and  such  firm  union  is  secured  that  a  ventral  hernia  seldom 
occurs  after  recovery. 

After  the  closure  of  the  wound,  that  part  of  the  abdomen 
which  has  been  exposed  is  carefully  dried  and  cleaned,  the 
india-rubber  cloth  removed,  and  the  wound  covered  with  some 
non-irritating  antiseptic  gauze,  or  boracic  wool,  and  supported 
by  long  strips  of  adhesive  plaster.     In  many  cases  the  false  ribs 


FAINTING  331 

have  been  pressed  outwards  by  the  tumour,  and  after  its  removal 
a  deep  hollow  is  left.  This  must  be  filled  up  with  pads  of 
cotton- wool.  A  flannel  belt  is  adjusted  around  her  abdomen, 
and  the  patient  is  then  gently  removed  to  her  bed.  She  is 
kept  on  her  back,  her  knees  supported  by  a  pillow,  is  covered 
with  light  but  warm  blankets,  and  provided  with  hot-water 
bottles,  if  she  is  at  all  chilly.  The  room  is  darkened,  and  she 
is  left  alone  with  her  nurse.  Dr.  W.  Webb  informs  me  that 
after  ovariotomy  and  other  serious  operations,  patients  rally 
much  more  rapidly  if  the  head  be  kept  warm,  covered  up  with 
a  shawl  or  flannel.  And  when  we  reflect  how  temperature  is 
lowered  by  cooling  the  head,  it  is  not  difficult  to  understand 
that  warming  the  head  until  reaction  after  shock  is  well  esta- 
blished may  be  very  advantageous.  If  reaction  is  slow  the 
head  should  not  be  raised  by  pillows,  but  kept  low. 

ACCIDENTS   DUKING   OPERATION. 

Fainting  is  an  accident  which  may  happen  in  any  operation, 
and  before  the  use  of  anaesthetics  was  not  uncommon.  I  have, 
however,  never  been  embarrassed  in  my  ovariotomies  by  this 
condition  of  the  patient.  And  only  in  one  case  has  the  methy- 
lene caused  any  trouble.  Then  the  pulse  became  for  a  little 
while  imperceptible,  and  we  were  obliged  to  give  a  small 
quantity  of  brandy.  After  swallowing  it  the  woman  rallied. 
She  had  some  thoracic  complication,  and  though  the  cyst  only 
contained  about  sixteen  pints  of  fluid,  yet,  as  the  removal  was 
very  quickly  over,  it  is  possible  that  the  enfeebled  heart  and 
lungs  were  unable  to  accommodate  themselves  to  the  sudden 
change  of  pressure. 

Out  of  the  127  deaths  which  followed  my  first  500  opera- 
tions, 20  were  put  down  as  the  effect  of  exhaustion,  and  none 
from  haemorrhage,  while  in  the  second  series  of  105  deaths 
there  were  only  eight  from  exhaustion  and  two  from  haemor- 
rhage. The  probability  is  that  some  of  the  first  series  of  deaths 
were  also  partly  due  to  bleeding,  but  the  fact  was  not  estab- 
lished by  examination.  The  deaths  from  exhaustion  were 
mostly  at  the  end  of  two  or  three  days,  but  in  one  as  early  as 
thirteen  hours.  No  case  of  collapse  after  the  operation  hap- 
pened in  the  second  series,  but  in  the  first  there  were  six  cases 


332  SHOCK  AND   HAEMORRHAGE 

— the  time  being  from  two  hours  to  about  forty  hours.  No 
death  has  ever  occurred  during  the  operations  either  from  shock 
or  the  anaesthetic. 

Thus  out  of  the  232  deaths  after  operation  only  36  are 
immediately  attributable  to  it,  under  the  heads  of  shock  and 
haemorrhage,  a  proportion  to  be  lessened  by  increased  ex- 
perience. The  remaining  mortality  of  196  was  due  to  other  and 
accidental  causes ;  and  considering  the  large  proportion  of  septic 
disease  which  proved  fatal  during  the  earlier  years,  was  to  a 
great  extent  avoidable,  and  the  result  of  inexperience.  The 
mortality  of  3*6  per  cent,  from  shock  and  haemorrhage  cor- 
responds very  nearly  with  the  results  of  Keith's  practice,  in 
which  there  are  very  few  deaths  recorded  as  from  secondary 
causes  ;  while  in  my  own  experience  in  private  cases  and  since 
adopting  Listerian  details,  amounting  to  173,  I  have  had  only 
three  immediate  deaths,  two  from  cardiac  embolism  in  about 
twenty  hours,  and  one  from  haemorrhage  almost  immediately 
after  the  patient  was  in  bed.  But  this  was  not  a  case  of  ovari- 
otomy only.  It  occurred  since  the  completion  of  the  1,000  cases, 
and  I  unwisely,  after  removing  an  ovarian  tumour,  attempted  to 
remove  a  cyst  of  the  liver.  In  one  case  of  secoDdary  bleeding 
which  came  on  shortly  after  the  operation  was  finished,  the 
patient  had  put  herself  into  a  violent  passion  in  consequence 
of  a  silly  remark  made  by  one  of  the  attendants.  An  intelli- 
gent nurse  saw  at  once  what  had  taken  place,  and  was  fortunate 
enough  to  find  me  not  far  off.  On  arriving  I  reopened  the 
wound,  put  another  ligature  on  the  pedicle  in  lieu  of  the  one 
which  had  slipped,  cleared  away  the  clots,  and  left  her  a  little 
weaker  but  not  the  worse  for  the  accident.  She  got  rapidly 
well,  but  died  this  year  of  cancer.  In  another  case  I  feared 
from  the  symptoms  that  the  ligature  had  slipped,  and  that  the 
patient  was  dying  of  internal  bleeding,  but  the  father  and 
brother  of  the  lady,  both  medical  men,  were  opposed  to  the 
reopening  of  the  wound,  and  would  not  permit  an  examina- 
tion after  death,  so  that  I  am  not  quite  sure  how  far  my  fear 
was  well  founded. 

Burst  cysts  and  suppurating  cysts  do  not  seem  to  have 
lowered  the  success  of  my  operations.  There  have  been  15 
such  cases,  12  burst  cysts,  and  3  suppurating  cysts,  among 
my  thousand  operations,  and  only  one  death  resulted. 


INJURIES   TO   VISCERA  333 

Injuries  to  viscera. — Several  cases  are  on  record,  and  I 
have  heard  of  others  not  recorded,  where  the  bladder  has  been 
injured  either  in  making  the  first  incision  or  in  separating 
adhesions  between  the  cyst  and  the  bladder.  Should  the 
bladder  be  injured,  the  opening  should  be  very  carefully  closed 
by  suture,  and  a  catheter  maintained  in  the  bladder  for  several 
days.  As  a  rule  the  effects  have  not  been  serious,  although  in 
some  cases  the  urine  has  drained  through  the  wound  for  several 
days.  In  one  case  where  I  had  cut  into  a  patent  urachus  from 
which  urine  escaped,  I  closed  the  opening  by  one  of  the  sutures 
which  closed  the  incision  in  the  abdominal  wall,  and  no  incon- 
venience followed.  The  rectum  has  been  torn  or  divided  during 
the  separation  of  adhesions,  in  some  cases  with  fatal  conse- 
quences ;  in  others,  where  accurate  closing  has  been  effected  by 
suture,  recovery  has  followed  without  any  foecal  fistula.  In  a 
patient  on  whom  I  operated  in  August  1876,  removing  both 
ovaries,  which  were  closely  united  to  each  other  behind  the 
uterus,  on  separating  attachments  between  the  uterus  and  the 
rectum,  I  tore  out  a  piece  of  the  rectum  as  large  as  a  sixpence, 
and  foecal  matter  escaped.  I  inverted  the  edges  of  the  opening 
so  as  to  bring  two  surfaces  of  the  peritoneum  in  apposition, 
united  them  by  a  continuous  silk  suture,  and  the  patient  reco- 
vered without  any  ill-effect  from  the  accident.  In  another  case 
operated  on  in  the  Samaritan  Hospital  in  June  1875,  in  re- 
moving an  enormous  malignant  growth  weighing  41  lbs.,  I  also 
detached  about  two  inches  of  small  intestine,  the  coats  of  which 
were  involved  in  the  disease.  The  upper  and  lower  ends  of 
the  gut  were  carefully  brought  together  and  united  by  peri- 
toneal suture,  but  the  patient  died  on  the  eleventh  day. 
Although  some  foecal  fluid  had  escaped  from  the  wound  in 
the  abdominal  wall,  the  bowels  had  acted  freely  in  a  natural 
manner,  and  it  appeared  that  the  wound  in  the  intestine  had 
but  little  to  do  with  the  fatal  result.  The  practical  lesson  from 
this  is  to  be  extremely  careful  when  separating  adhesions 
between  the  cyst  and  intestine,  and  if  the  intestine  is  either 
accidentally  wounded,  or  a  diseased  portion  is  intentionally 
removed,  the  union  of  the  peritoneal  edges  by  fine  sutures  must 
be  very  carefully  and  accurately  completed.  In  December  1881 
Professor  Billroth  in  making  a  double  ovariotomy  was  obliged 
to  resect  part  of  the  bladder  and  some  inches  of  small  intestine 


334  INJURIES   TO   VISCERA 

on  account  of  very  strong  adhesions  between  these  parts.     I 
have  not  heard  how  the  case  ended. 

The  liver  has  been  injured  during  the  separation  of  ad- 
hesions. In  one  case,  in  an  insane  patient,  under  the  care  of 
Mr.  Archer,  of  St.  John's  Wood,  I  removed  some  ounces  of  the 
lower  edge  and  under  surface  of  both  lobes  of  a  large  liver.  I 
had  considerable  trouble  in  stopping  the  bleeding,  and  applied 
perchloride  of  iron  freely.  The  ovarian  cyst  for  which  I  was 
operating  was  a  very  large  one,  and  the  patient  in  an  extremely 
feeble  condition  after  repeated  tappings,  yet  she  recovered 
as  rapidly  and  completely  as  in  the  most  simple  case,  is  still 
alive,  and  has  regained  her  soundness  of  mind  as  well  as  body. 
In  one  other  case,  already  alluded  to,  I  lost  a  patient  from 
haemorrhage  after  opening  a  cyst  which  projected  from  the 
under  surface  of  the  liver,  the  walls  of  which  poured  out  blood 
with  extreme  rapidity  in  spite  of  all  efforts  to  check  it. 

I  have  never  met  with  a  case  in  which  the  spleen  has  been 
injured  during  ovariotomy ;  but  an  enlarged  spleen  has  been 
occasionally  mistaken  for  an  ovarian  tumour,  and  splenic  cysts 
mistaken  for  ovarian  cysts  have  been  removed  more  than  once 
successfully,  though  generally  with  a  fatal  result.  Should  either 
of  these  mistakes  be  recognized  after  beginning  an  operation,  the 
surgeon  must  act  exactly  as  if  he  were  doing  splenotomy. 

The  kidney. — Enough  has  been  said  about  renal  cysts  and 
tumours  to  render  it  unnecessary  to  say  more  than  that  if  a 
kidney  should  be  unavoidably  or  accidentally  removed  with,  or 
instead  of,  an  ovarian  tumour,  as  much  care  would  be  called  for 
in  securing  the  blood-vessels  as  in  a  case  of  nephrotomy  planned 
beforehand.  One  or  both  ureters  are  known  to  have  been 
divided  or  tied  accidentally.  In  Simon's  famous  case,  where 
a  urinary  fistula  remained  after  injury  to  the  right  ureter, 
Simon  removed  the  right  kidney,  and  I  saw  the  woman  some 
months  afterwards  in  excellent  health.  In  a  similar  case 
Nussbaum,  instead  of  removing  the  kidney,  re-established  com- 
munication between  the  kidney  and  the  bladder  by  a  series  of 
patient  manoeuvres,  of  which  he  has  published  an  interesting 
account.  It  is  remarkable  that  in  cases  of  adhesions  low  down 
in  the  pelvis  the  ureters  should  escape  injury  so  often  as  they 
do.  I  suspect  that  their  condition  has  been  overlooked  in 
some  post-mortem  examinations,  and  it  is  extremely  probable 


ACCIDENTS   WITH   SPONGES   AND   INSTRUMENTS  335 

that  in  some  of  the  cases  where  suppression  of  urine  has  been 
a  prominent  symptom,  one  or  both  ureters  may  have  been 
injured. 

After  passing  the  sutures  which  are  to  close  the  abdominal 
wall,  and  before  tying  them,  the  sponges  and  forceps  should  be 
counted.  It  is  a  good  plan  to  take  the  same  number  of  sponges 
and  forceps  to  every  operation.  By  forceps  I  mean  the  torsion 
or  pressure-forceps,  the  use  of  which  has  been  already  described. 
'Of  these  I  always  take  twelve,  of  sponges  twenty.  If  any 
other  than  the  usual  fixed  number  be  taken,  some  doubt  is 
almost  certain  to  arise  when  the  nurse  is  told  to  count  the 
sponges.  Very  small  sponges  are  so  easily  lost,  that  it  is  advis- 
able not  to  use  any  which  when  wet  are  smaller  than  an  ordi- 
nary closed  fist.  Even  then  it  may  not  be  easy  to  find  one 
when  wet  in  the  peritoneal  cavity.  It  is  a  good  rule  for  the 
surgeon  strictly  to  forbid  either  of  his  assistants  to  put  a  sponge 
within  the  abdominal  cavity.  No  one  should  be  allowed  to 
divide  a  sponge.  One  of  my  friends  abroad  writes  that  in  one 
of  his  fatal  cases  a  sponge  was  found  in  the  peritoneal  cavity. 
He  had  suspected  that  a  sponge  might  be  within  the  abdomen 
at  the  end  of  the  operation,  but  could  not  find  it,  and  on 
counting  the  sponges  the  number  was  complete.  It  afterwards 
appeared  that  one  had  been  torn  into  two  by  one  of  the  nurses. 
No  one  who  has  not  tried  it  can  understand  how  difficult  it 
may  be  sometimes  to  find  a  lost  sponge. 

In  my  lectures  as  Hunterian  Professor  at  the  Royal  College 
of  Surgeons  in  June  1878,  I  gave  the  following  account  of  the 
only  case  in  which  I  left  a  pair  of  forceps  in  the  abdomen. 
'  Not  very  long  ago  I  removed  both  ovaries  from  a  young 
married  lady,  and  a  great  many  forceps  were  used.  After 
removing  one  ovary  and  securing  the  pedicle,  the  other  ovary 
had  to  be  removed.  It  had  a  very  short  pedicle,  and  five  or 
six  of  my  torsion-forceps  were  put  on  in  order  to  secure  the 
bleeding  vessels,  while  I  was  tying  them  separately.  I  took 
off,  as  1  thought,  every  pair  of  forceps,  closed  the  wound  up, 
and  everything  seemed  quite  as  it  should  be.  But  about  two 
hours  after  the  operation  I  received  a  message  from  a  friend 
who  was  putting  up  the  instruments  for  me,  to  say  there  was  a 
pair  of  forceps  missing.  We  knew  exactly  the  number  of 
forceps ;  if  we  had  not  known  that,  one  pair  would  not  have 


336  FORCEPS 

been  missed.  This  shows  how  necessary  it  is  always  to  know 
how  many  forceps  are  taken.  It  was  about  live  in  the  afternoon 
when  I  had  this  message :  "  There  was  a  pair  of  forceps  missing, 
probably  they  might  be  in  the  patient."  Imagine  the  sort  of 
feeling  with  which  one  would  receive  that  intimation.  I  at 
once  went  to  the  patient.  She  seemed  so  well  that  I  did  not 
like  to  disturb  her ;  there  was  some  doubt  where  the  forceps 
might  be,  so  I  thought  I  would  wait  a  little  longer.  I  waited 
till  night ;  she  still  seemed  pretty  well,  and  I  thought  I  would 
wait  till  the  morning ;  but  in  the  morning  the  nurse  told  me 
the  lady  had  been  very  restless.  I  then  made  a  very  careful 
examination,  by  the  vagina,  and  rectum,  and  abdominal  wall, 
to  see  if  I  could  feel  the  forceps,  but  there  was  nothing  to  be 
felt  at  all.  Still  I  was  uneasy,  and  I  thought  I  had  better  open 
the  wound.  So  I  asked  Mr.  Thornton  to  come  with  me  and 
throw  some  carbolic  spray  over  the  abdomen,  and  making  some 
excuse  to  the  patient,  just  saying  I  thought  it  necessary  to 
change  the  dressing,  and  it  would  be  as  well  that  she  should 
not  feel  it,  we  gave  her  methylene,  removed  the  dressing,  and 
took  out  two  stitches.  I  put  one  finger  in,  but  at  first  could 
not  feel  the  forceps.  At  last  I  found  something  hard,  put 
another  finger  in,  and  found  the  forceps  wrapped  up  in  the 
omentum.  From  the  way  in  which  the  omentum  had  insinuated 
itself  into  the  ring  handles  of  the  forceps  and  between  the 
blades,  it  was  easy  to  understand  how  difficult  it  was  to  find 
and  remove  the  instrument ;  but  I  did  it,  returned  the  omen- 
tum, closed  the  wound,  and  the  patient  was  none  the  worse. 
She  got  well,  and  to  this  day  does  not  know  that  anything 
unusual  occurred.' 

I  purposely  avoid  relating  a  case  (No.  917)  where  a  pair  of 
forceps  was  found  in  the  bladder  of  a  patient  a  month  after 
recovery  from  ovariotomy,  as  the  occurrence  is  still  to  me 
inexplicable. 


DOUBLE   OVARIOTOMY  337 


CHAPTER   X. 

ON  THE  REMOVAL  OF  BOTH  OVARTES  AT  ONE  OPERATION 

In  the  chapter  on  the  performance  of  ovariotomy  twice  on  the 
same  patient  particulars  will  be  found  of  thirteen  cases  where 
the  patient  recovered  after  the  removal  of  one  ovary,  after 
some  months  or  years  became  the  subject  of  disease  in  the 
other  ovary,  and  underwent  a  second  time  the  operation  of 
ovariotomy.  Eleven  recovered  and  two  died  after  this  second 
operation.  In  that  chapter  some  remarks  will  be  found  upon 
the  comparative  frequency  of  disease  in  one  or  both  ovaries 
bearing  upon  the  subject  of  the  present  chapter ;  namely,  the 
removal  of  both  ovaries  at  one  operation. 

It  has  been  already  explained  how,  after  removing  one 
ovarian  tumour,  the  surgeon  should  search  for  and  examine  the 
other.  In  the  large  majority  of  cases  the  other  ovary  is  healthy, 
and  should  not  be  disturbed;  but  occasionally  it  is  more  or  less 
enlarged ;  and  it  becomes  a  question  whether  it  should  be  re- 
moved, whether  any  cysts  projecting  from  its  surface  should 
be  punctured  and  their  contents  squeezed  out,  or  whether  it  is 
more  prudent  to  be  content  with  the  removal  of  one  ovary, 
hoping  that  the  other  will  never  increase  sufficiently  to  need 
surgical  interference,  or  at  any  rate  postponing  that  interference 
till  after  recovery  from  the  first  operation.  In  determining 
which  of  these  lines  of  practice  to  follow,  the  age  of  the  patient, 
her  conjugal  condition,  and  the  ease  or  difficulty  with  which 
the  second  operation  could  be  performed,  are  the  leading  points 
for  consideration. 

There  can  be  no  doubt  that  the  removal  of  the  second  ovary 
does  add  to  the  danger  of  the  single  operation.  If  we  deduct 
from  the  one  thousand,  eighty-two  cases  where  both  ovaries 
were  removed,  this  would  reduce  the  number  of  single  opera- 

z 


338  CONSEQUENCES   OF   REMOVING   BOTH   OVARIES 

tions  to  918  and  the  deaths  to  204,  with  a  mortality  of  22*2 
per  cent.  But  as  of  the  eighty-two  cases  of  double  ovariotomy 
twenty-eight  died,  the  mortality  is  34*14  per  cent.,  or  more 
than  12  per  cent,  above  that  of  the  single  cases.  This  is  quite 
sufficient  to  show  that  the  surgeon  should  hesitate,  and  cer- 
tainly not  remove  the  second  ovary  without  good  reason.  I 
have  several  times  been  begged  by  patients  before  the  operation 
to  remove  the  second  ovary,  even  if  it  were  healthy  and  the 
risk  of  the  operation  increased,  in  order  that  they  might  be 
spared  from  the  possibility  of  being  again  subject  to  similar 
disease ;  and  medical  men  have  occasionally  supported  this  not 
unnatural  wish  of  the  patient.  I  have  always  replied  that  I 
should  object  to  the  removal  of  a  healthy  organ  if  that  removal 
endangered  the  success  of  an  operation  which  was  clearly  neces- 
sary ;  that  as  a  rule  the  removal  of  one  ovary  would  not  be 
followed  by  disease  of  the  other,  that  the  double  operation 
would  necessarily  render  the  woman  sterile,  and  that  there 
might  possibly  be  some  consequences  of  the  removal  of  both 
ovaries,  such  as  an  undue  deposit  of  fat,  or  obscure  nervous 
symptoms,  or  some  change  in  feminine  physiological  peculiari- 
ties, which  would  be  objectionable  if  not  directly  prejudicial. 
For  these  reasons  I  am  of  opinion  that  a  healthy  ovary  should 
not  be  removed  from  any  woman  at  any  age,  unless  Battey's 
operation  has  to  be  considered.  This  subject  will  be  treated  in 
a  subsequent  chapter.  The  amount  of  apparent  disease  in  an 
ovary  which  would  justify  the  removal  of  the  organ  may  vary 
with  the  age  and  condition  of  the  patient.  In  a  woman  past 
the  age  of  child-bearing  a  small  amount  of  apparent  disease 
would  justify  removal  of  the  ovary,  whereas  a  surgeon  should 
hesitate  before  he  condemns  a  young  woman  to  permanent 
sterility.  It  has  been  suggested  that  in  every  woman  past  the 
age  of  child-bearing,  if  one  ovary  has  to  be  removed,  both 
should  always  be  taken  away  to  avoid  the  possibility  of  recur- 
rence of  disease  calling  for  a  second  ovariotomy.  But  one  would 
hardly  be  justified  in  adding  anything  to  the  risk  of  a  first 
operation  on  so  small  a  probability  as  there  is  of  recurrence  of 
non-malignant  disease  on  the  other  side. 

Sometimes  during  an  operation,  after  removal  of  one  ovary, 
some  slight  alteration  in  the  other  may  be  observed,  and  the 
question  of  removal  of  the  second  ovary  may  arise.     In  many  of 


OBJECTIONS   TO   REMOVAL   OF   BOTH   OVARIES  339 

my  cases  this  question  has  arisen.  In  narrating  the  112th 
case  of  ovariotomy  in  my  first  work  on  '  Diseases  of  the  Ovaries,' 
after  recording  the  removal  of  the  right  ovary  from  a  young 
lady  aged  nineteen,  I  continue,  p.  307  : — 

6  The  left  ovary  was  enlarged  to  nearly  double  the  normal 
size.  Two  follicles,  about  the  size  of  cherries,  were  distended 
by  clot.  These  I  laid  open,  turning  out  their  contents.  .  .  . 
The  operation  was  peculiar  on  account  of  the  doubt  as  to  the 
treatment  of  the  left  ovary.  I  resolved,  after  consulting  with 
Dr.  Grreenhalgh  (who  was  assisting  me),  not  to  remove  it, 
because — 

'  a.  The  ligature  which  would  have  been  necessary  would 
have  added  seriously  to  the  risk  of  the  operation. 

(  b.  It  is  not  certain  that  disease  was  present  in  the  ovary, 
or  that  it  would  progress,  and,  if  it  did,  a  second  ovariotomy 
could  still  be  done. 

'  c.  It  seemed  hard  to  unsex  a  girl  of  nineteen.  Perhaps 
the  clots  might  have  been  left  alone,  but  turning  them  out 
could  do  no  harm,  and  might  do  good.' 

This  operation  was  performed  in  November  1864.  The 
patient  recovered  well,  went  into  the  country  four  weeks  after 
operation,  was  married  in  August  1865,  and  is  now  the  mother 
of  three  girls  and  a  boy,  born  in  September  1866,  March  1868, 
September  1869,  and  July  1871.  Mr.  Morgan,  who  attended 
her,  informed  me  that  all  the  pregnancies  and  labours  were 
perfectly  natural,  and  she  remains  well  in  1881. 

Of  the  82  cases  in  which  both  ovaries  were  removed  at  one 
operation,  20  were  fifty  years  of  age  or  more,  18  were  between 
forty  and  fifty,  and  31  were  under  forty.  Forty- three  were 
married,  36  single,  and  3  were  widows. 

Both  ovaries  removed  at  same  operation. 

Cases  Deaths  Mortality  per  cent. 

In  first  series   .....     25  11  44 

In  second  series       .         .         .57  17  29-82 

In  the  1 ,000  82  28  34-14 

In  first  series    8  were  over  50  years      In  second  series      .     12   =   20 

„  4  between  40  and  50  „  .     14   =   18 

13  under       40  ,,  .     31   =   44 


82 


z  2 


irried 

Single 

Widow 

17 

7 

1 

26 

29 

2 

340  RESULTS  OF  VARIOUS  MODES  OF 


In  first  series         .... 
In  second  series    .... 

43  36  3 

Of  the  14  surviving  in  the  first  series  6  are  not  only  alive,  but  well,  in  1881, 
at  the  ages  of  71,  63,  53,  52,  45,  and  31,  and  they  have  divided  between  them 
77  years  of  life  and  health  gained  by  the  operation.  Five  have  died  of  other 
diseases  after  getting  about  fifteen  years  of  life.  Three  have  made  no 
report. 

Of  second  series  27  are  well  in  1881  (two  married) ;  17  died  after  ope- 
ration, 11  septicaamia,  2  haemorrhage.  1  exhaustion,  1  abscess ;  4  have  died  of 
cancer  since  ;  and  4  of  other  diseases  since ;  no  reports  of  5  since  1876. 

In  one  case  there  were  three  ovaries. 


The  chief  point  of  practical  importance  in  double  ovari- 
otomy is  the  mode  of  dealing  with  the  pedicle.  In  the  double 
cases  among  the  first  500  I  once  secured  both  pedicles  by  one 
clamp,  and  once  used  two  clamps,  one  on  each  pedicle,  and  kept 
both  clamps  outside  with  no  more  inconvenience  to  the  patient 
than  if  one  clamp  only  had  been  used,  and  with  a  completely 
successful  result.  In  another  case  I  tried  to  do  this,  but  the 
pedicles  were  too  large.  I  accordingly  transfixed  them  by  a  large 
pin  and  tied  both  pedicles  together  behind  the  pin.  The  pin  thus 
became  a  sort  of  clamp  and  secured  the  extra-peritoneal  separa- 
tion of  the  pedicle.  I  have  also  secured  one  pedicle  by  a  clamp 
and  the  other  by  ligature,  fixing  the  latter  to  the  clamp,  in  this 
way  conveniently  effecting  the  extra-peritoneal  mode  of  treat- 
ment. More  than  once,  after  securing  one  pedicle  by  a  clamp, 
owing  to  the  absence  of  a  pedicle  to  the  other  tumour,  I  trans- 
fixed and  tied  the  attachment,  cut  the  ends  of  the  ligatures 
off  short,  and  left  them  in  the  abdomen.  I  also  treated  both 
ovaries  in  this  manner,  and,  after  tying  one  or  both  pedi- 
cles, I  brought  the  ligatures  out  through  the  wound.  The 
results  before  adopting  complete  intra-peritoneal  ligature  and 
antiseptic  treatment  were  strongly  in  favour  of  the  extra-peri- 
toneal method  of  dealing  with  both  pedicles.  Thus  of  nine 
cases  where  both  pedicles  were  fixed  outside  by  one  or  two 
clamps,  or  by  applying  a  clamp  on  one  pedicle  and  fixing  the 
ligature  on  the  other  to  the  clamp,  or  using  a  pin  to  transfix 
the  pedicles  and  tying  them  behind  the  pin,  which  thus  became 
a  sort  of  clamp,  in  either  way  securing  both  pedicles  outside 


DEALING   WITH   THE   TWO    PEDICLES  341 

the  abdominal  wall,  seven  recovered  and  only  two  died.  Of  six 
cases  where  the  pedicle  on  one  side  was  kept  out  by  the  clamp, 
and  the  other  pedicle  tied,  the  ligature  being  left  in,  four 
recovered  and  two  died.  Of  six  cases  where  both  pedicles  were 
tied  and  the  ligatures  left  in,  four  died  and  two  recovered.  Of 
four  cases  where  the  ligatures  were  brought  outside,  acting  as 
a  drain  and  keeping  the  lower  angle  of  the  wound  open,  only 
one  recovered  and  three  died.  Of  those  who  recovered,  one 
died  two  years  afterwards  of  hemiplegia,  another  two  years 
afterwards  of  cardiac  dropsy,  and  a  third  six  months  after  opera- 
tion of  peritoneal  cancer.     Ten  were  in  good  health  in  1872. 

In  57  double  operations  in  the  second  series  of  500  I  used 
the  clamp  and  ligature  ten  times — once  the  clamp  alone,  and 
for  the  other  forty- six  I  put  on  ligatures. 

In  the  following  table,  particulars  may  be  found  of  the 
thousand  cases  in  which  I  have  completed  the  operation  of 
ovariotomy,  where  one  or  both  ovaries  have  been  removed  at 
the  same  time. 


342 


TABLE   OF  ONE  THOUSAND  CASES 


Medical  Attendant 


Hospital       .... 

Hospital       .... 
Hospital       .... 

Hospital  .... 

Hospital  .... 

Hospital  .... 

Hospital  .... 

Hospital  .... 

Dr.  Eidsdale 

Mr.  Huxtable 

Hospital       .... 

Mr.  Whipple,  Plymouth     . 
Mr.  Peirce,  dotting  Hill    . 

Hospital       .... 
Hospital       .... 

Dr.  Whitehead,  Manchester 
Hospital      .... 

Dr.  Eaniskill 

Dr.  Eigby    .... 

Mr.  McCrea,  Islington 

Hospital       .... 

Dr.  Grimsdale,  Liverpool  . 

Dr.  Bainbridge   . 

Hospital       .... 

Hospital       .... 

Hospital       .... 

Hospital       .... 

Dr.  Grant    .... 
Dr.  West      .       .       .       . 

Hospital      .... 


Date 

of 

Operation 

Age 

1858  Feb. 

29 

„    Aug. 

38 

„    Nov. 

33 

1859  Jan. 

39 

„    May 

43 

„    June 

29 

„    June 

29 

,,    July 

47 

„    Oct. 

41 

„    Oct. 

37 

„    Oct. 

29 

„    Oct. 

38 

„    Nov. 

17 

„    Dec. 

27 

1SG0  Jan. 

23 

„    Feb. 

26 

„    Feb. 

33 

»   July 

41 

>,   July 

36 

„    Oct. 

53 

1861  Jan. 

54 

„    March 

22 

„    April 

55 

„    April 

42 

„    June 

34 

,.   July 

31 

„    Aug. 

27 

»    Aug. 

35 

„     Oct. 

51 

„    Dec. 

50 

Condition 


Single 

Married 
Married 

Single 

Married 

Married 

Single 

Married 

Married 

Single 
Single 

Married 
Single 

Single 
Single 

Married 
Married 

Married 

Single 

Married 

Married 

Single 

Married 

Married 

Single 

Married 

Single 

Single 
Married 

Single 


Parietal  and  intestina 
Omental  and  intestim 

Omental  and  intestin 
Omental  and  intestin 
Parietal    and    oment 

Parietal  and  omental 
Parietal  and  omental 

Parietal  and  omental 

Parietal  and  omental 
Parietal  and  omental 

Parietal  and  omental 
Parietal  and  omental 

Parietal  and  omental 

1 

il 

il 

il 
al 

343 


OF   COMPLETED   OVAPJOTOMY 


Treatment  of 
Pedicle 

Weight  of 
Tuniour 

Length 

of 
Incision 

Result 

Subsequent  History 

or 

Cause  of  Death 

No. 

1 

Ligature 

26  pounds 

3  inches 

Eecovered 

Married.    "Well  in  Australia  20  years 
after  operation 

Ligature 

31       „ 

4      „ 

Recovered 

Died  7  years  after  from  cancer 

2 

Clamp 

81      ,, 

4      „ 

Recovered 

Died  10  months  after  of  peritoneal 
cancer 

3 

Clamp 

10      „ 

7      „ 

Died,  32  hours 

Septicaemia 

4 

Clamp 

10      „ 

4      ,, 

Recovered 

"Well  in  1881 

5 

Clamp 

7      „ 

4      „ 

Died,  2nd  day- 

Peritonitis 

6 

Clamp 

? 

6      „ 

Recovered 

WeU  in  1881— still  single 

7 

Clamp. 

Both 

? 

Recovered 

Died  2  years  after  of  hemiplegia 

8 

ovaries 

Clamp 

38      „ 

5       „ 

Recovered 

Girl  born  13  months  after  operation, 
labour  easy— remains  well,  1881 

9 

Clamp 

19      „ 

7      „ 

Died,  4th  day 

Peritonitis 

10 

Clamp 

42       „ 

4      „ 

Recovered 

Well  in  1872 — died  a  few  years  ago 
from  some  other  disease 

11 

Clamp 

53       „ 

4      „ 

Died,  9th  day 

Tetanus 

12 

Ligature 

38      „ 

4      „ 

Recovered 

Married  June  1865 — 3  boys  and  2  girls 
since,  labours  all  natural.  "Well  in  1881 

13 

Clamp 

54      „ 

4      „ 

Died,  23  hours 

Collapse 

14 

Clamp  and  liga- 
ture 

25      „ 

5     ., 

Recovered 

Married  1865 — 1  boy  and  1  girl  since. 
Well  in  1881 

15 

Ligature 

25      „ 

4      )> 

Died,  30  hours 

Septicaemia 

16 

Clamp  and  liga- 
ture 

31       „ 

7      „ 

Died,  46  hours 

Intestinal  obstruction 

17 

Pin   and 
tare 

liga- 

26      „ 

4      „ 

Recovered 

WeU  in  1871 

18 

Pin   and 
tare 

liga- 

24      „ 

4      „ 

Recovered 

Married  1878.    "WeU  in  1881 

19 

Pin    and 
tare 

liga- 

58      „ 

4      „ 

Recovered 

Health  very  good  in  1881,  aged  74 

20 

Pin   and 
tare 

liga- 

20      „ 

6      „ 

Recovered 

No  report 

21 

Pin   and 
tare 

liga- 

16      „ 

3      „ 

Recovered 

Married    in    1869—3     children — girl 
1871,  boy  1873,  girl  1875.    Alive  in 
1881 

22 

Pin   and 
tare 

liga- 

20      „ 

3      „ 

Recovered 

Died  in  1871 

23 

Pin   and 

tUl'C 

liga- 

3      „ 

Died,  24  hours 

Septicaemia 

24 

Pin    and 
tare 

liga- 

55      ,, 

6      „ 

Died,  5th  day 

Exhaustion 

25 

Pin  and 
tare 

liga- 

50      „ 

5      „ 

Died,  3rd  day 

Exhaustion 

26 

Pin   and 
ture 

liga- 

44      „ 

4      „ 

Recovered 

Had  child  20  months  after  operation, 
labour  easy.     Well  in  1872 

27 

>7      „ 

4      „ 

Recovered 

Well  in  1881 

28 

i  and  liga- 
ture 

35      „ 

•5      ,. 

Died,  47  hours 

Peritonitis 

29 

Clamp 

40      „ 

Recovered 

Operated  on  a  second  time,   Feb.  5, 
1808,  and  died  Uct.  0,  1868,  phthisis 

30 

344 


TABLE   OF   ONE   THOUSAND   CASES 


31  I  Dr.  Lawford,  Leighton  Buzzard 

Hospital 

Dr.  Markham     . 

Dr.  Whitehead,  Manchester 

Hospital      .        .  .        . 

Hospital      .  . 

Hospital  . 

Dr.  West     . 


Hospital 
Hospital 


Hospital      .        .        . 
Dr.  Cahill,  Brompton , 


Hospital 


Hospital 
Hospital 


Dr.  Walshe . 
Dr.  Hawksley 
Hospital 


Dr.  Grimsdale,  Liverpool 

Hospital 

Hospital 

Dr.  Martin,  Bochester 

Hospital 


Sir  T.  Watson     . 

Hospital 

Hospital 

Dr.  Hare 

Hospital 

Dr.  Cooper,  Brentford 

Hospital 

Hospital 

Hospital 


Dr.  Dyce,  Aberdeen    . 
Dr.  Churchill,  Dublin 


Hospital 

Hospital 

Dr.  Dyce,  Aberdeen    . 

Dr.  Llewellyn  Williams 


69  J  Dr.  F.  Bird 


1861  Dec. 

1862  Jan. 
,,  Jan. 
,,  Jan. 
„  May 
,,  May 
,,  June 
,,    June 

„    June 

»   July 


Age     Condition 


Married 

Single 

Married 

Married 

Single 

Married 

Married 

Single 

Married 
Single 


Adhesions 


July       41       Single 
Sept.      49       Single 


„  Oct. 

„  Oct. 

„  Oct. 

„  Not. 

„  Nov. 

„  Nov. 

„  Nov. 

„  Nov. 

„  Dec. 

„  Dec. 
1863  Jan. 

„  Feb. 

„  Feb. 

„  Marcl 

„  Marcl 

„  Marcl 

„  Marcl 

„  Marcl 

„  April 

,,  April 

„  April 

„  May 

„  June 

,,  June 

„  June 

„  June 


Single 

Married 
Single 

Single 
Single 
Married 

Single 

Single 

Married 

Single 

Married 

Single 

Married 

Single 

Single 

Single 

Single 

Married 

Married 

Single 

Married 
Married 

Married 
Married 
Married 

Single 

Single 


Parietal  and  omental . 

Parietal  and  intestinal 

Omental  and  intestinal 

Parietal 

Omental  and  intestinal 

Parietal  and  omental 

Omental 

None   .... 

Parietal 

Parietal  and  omental . 


Parietal  and  omental . 
Parietal 

None 

Parietal  and  omental . 

None 

None 

None 

Parietal  and  omental . 

Parietal 

Parietal  and  omental . 
Parietal  and  omental . 

None 

Parietal 

Parietal  and  omental . 

Parietal 

Parietal 

Parietal       .        . 

None 

None 

Parietal  and  intestinal 
Parietal  and  intestinal 
None 

Parietal,  omental,  and  intestinal 
None 

Parietal  and  omental . 

Parietal 

Parietal  and  omental . 

None 

None 


OF  COMPLETED    OVARIOTOMY 


345 


Treatment  of       Weight  of 
Pedicle  Tumour 


Clamp 
Wire  Clamp 
Clamp 
Clamp 
Clamp 
Clamp 
Clamp 
Ecraseur . 


Ligature , 
Clamp 


Clamp 
Clamp 

Clamp 

Clamp 
Clamp 

Clamp 
Clamp 
Clamp 

Clamp 
Clamp 
Clamp 
Clamp 
Clamp 

Clamp 

Clamp 

Clamp 

Clamp 

Clamp 

Clamp 

Ligature 

Clamp 

Clamp 

Clamp 
Clamp 

Clamp 
<  lamp 
I  lamp 

Clamp 


27  pounds 


Length 

of 
Incision 


7   „ 
25   „ 

72   „ 
30   „ 

36   „ 
48   „ 
15   „ 

30   „ 

16 

47 

20   „ 

36 

38   „ 

9  inches 
5       „ 
5       „ 
5       » 
5 


Subsequent  History 

or 

Cause  of  Death 


Died,  13th  day 
Died,  30  hours 
Died,  5th  day 
Died,  3rd  day 
Died,  13th  day 
Recovered 
Recovered 
Recovered 

Recovered 
Recovered 


Recovered 
Recovered 


Recovered 
Died,  40  hours 

Recovered 
Recovered 
Recovered 

Recovered 
Recovered 
Recovered 
Recovered 
Recovered 

Died,  44  hours 

Recovered 

Recovered 

Recovered 

Recovered 

Died,  27th  day 

Died,  54  hours 

Recovered 

Recovered 

Recovered 
Recovered 

Died,  54  hours 
Recovered 
Died,  80  hours 
Recovered 


Peritonitis 

Diffuse  peritonitis 

Exhaustion 

Septicemia 

Tetanus 

Died  of  spinal  meningitis,  July  1868 

Well  in  1872.    No  report  since 

Married  1863— 1st  child  bom  1864, 
2nd  1866,  3rd  1868.  Uterine  fibroid 
removed  June  1869  ;  died  third  day 

Married  April  1861— no  child.  WeU 
in  1881 

Married  July  1867,  and  again  Aug. 
1870.  Well  in  1881  after  death  of 
her  third  husband.  Chi  dren  bom 
in  1871  and  1872 

Well  and  single  in  1881 

Well  and  single  in  1872. 


No  report 


Was  tapped  per  vag.    Aug.  1S64.    Well 
and  single  in  1872,  died  in  1874 

Died  1 869  of  bronchitis 

Peritonitis,  with  fatty  liver  and  en- 
larged spleen 

Well  in  1881 — single — menses  regular. 

No  report 

Died  Nov.  1881  in  her  74th  year  of 
heart  disease 

Married  1880  in  America.  Well  in  1881 

Well  in  1870.    No  report  since 

Health  good  in  1881 

Well  and  single  in  1881 

Boy  born  April  1864  ;  girl  1865 — 
labours  natural.    Well  in  1881 

Diffuse  peritonitis 

Well  in  1872.    No  report  since 

Well  in  1872,  since  dead 

WeU  and  single  in  1881 

No  report 

Pyajmic  pleurisy 

Septicasmia 

Died  Aug.  1863  of  cancer 

Married  1869  ;  girl  born  August  1870, 
labour  natural ;  well  and  pregnant 
in  1872.    No  further  report 

Died  of  diffuse  cancer  in  3  months 

Boys  born  July  1865  and  Sept.  1867, 
labours  natural.    Well  in  1881 

Fibrinous  clot  in  heart 

Well  in  1881 

Exhaustion 

Married  Nov.  1868.  Boy  still-born  at 
6  months  May  1869  ;  girl  July  1870. 
Well  in  1881 

Well  and  single  in  1881 


346 


TABLE    OF   ONE   THOUSAND   CASES 


Medical  Attendant 


Hospital 
Hospital 

Mr.  Baker,  Birmingham 
Dr.  Symonds,  Clifton 
Dr.  Gordon,  Dublin    . 
Dr.  Hutton,  Dublin    . 
Hospital 
Hospital 


Hospital 
Hospital 

Dr.  Fox 


Hospital 

Sir  E.  Hilditch   . 

Dr.  CabiH    . 

Mr.  Stretton,  Beverley 


Hospital 
Dr.  Playfair 


Hospital     .        .        . 

Dr.  Collet,  "Worthing . 

Dr.  Pickford,  Brighton 

Hospital 

Dr.  Farre    . 

Hospital 

Sir  T.  Watson     . 

Mr.  Carden,  Worcester 


Hospital 

Sir  W.  GuU 

Mr.  Kidsdale 

Dr.  Brown,  Haverfordwest 

Hospital 

Hospital 


Hospital 
Hospital 


Mr.  Picken,  Croydon  , 
Sir  J.  G.  Simpson 


Date 

of 

Operation 


1863  June 

.,  July 

„  July 

„  Aug. 

»  Aug. 

„  Sept. 

„  Oct. 

„  Oct. 

„  Nov. 

„  Nov. 

„  Nov. 

„  Nov. 

„  Dec. 

,,  Dec. 


Feb. 
March 


March 

April 
April 
April 
April 
April 
April 

May 
May 
May 
May 

May 

June 

June 
July 

July 

July 


Married 
Single 

Single 

Single 

Single 

Single 

Married 

Single 

Single 
Single 

Single 

Married 
Married 
Married 

Single 


Married 
Married 

Single 

Single 

Single 

Married 

Married 

Married 

Single 

Married 

Married 
Single 
Single 
Married 

Single 

Married 

Single 

Single 

Married 
Married 


Parietal  and  intestinal 
None  .... 

None  .... 
None  .... 
None  .... 
None   .... 

Omental 

Parietal       .        .        . 

Parietal 

None    .... 

None    .... 

Omental 

Intestinal    .        .        . 

None   .... 

None   .... 

Omental 

Omental  and  pelvic    . 

None  .       .        .        . 

Parietal 

None  .... 
None  .... 

Parietal 

Parietal  and  omental 

None    .... 

Parietal 

None    .... 

None   .        .        .        . 

Parietal 

None   .... 

Parietal 

None   .        .       .       . 

Parietal  and  omental 

Omental 

Parietal  and  pelvic 
None   . 


OF   COMPLETED    OVARIOTOMY 


347 


Treatment  of 
Pedicle 

Weight  of 
Tumour 

Length 

of 
Incision 

Result 

Subsequent  History 

or 

Cause  of  Death 

No. 
70 

Recovered 

Well  in  1872 

Clamp  and  liga 
tnre 

21  pounds 

4      ,, 

Died,  78  hours 

Clot  in  heart 

71 

4      „ 

Died,  44  hours 

Exhaustion 

72 

Recovered 

Well  and  single  in  1881 
Peritonitis 

73 

4      „ 

Died,  82  hours 

74 

Clamp 

16      „ 

5      » 

Died,  40  hours 

Peritonitis 

75 

7      „ 

Recovered 

No  report 

76 

8      „ 

Recovered 

Married  since — six  children.    Well  in 
1881 

77 

Clamp 

4      „ 

Died,  8th  day- 

Peritonitis 

78 

Clamp 

17      „ 

4      „ 

Recovered 

Well  and  single  in  1881,  but  with  en- 
larged abdomen 

79 

4      „ 

Recovered 

Married  1864.     Girls  born  1865  and 
1867  ;    boy  1870  ;   labours   natural. 
Well  in  1872.    No  report  since 

80 

Ligature  . 

44      „ 

5     » 

Died,  8th  day 

Septicaemia 

81 

5      ,, 

Died,  3rd  day 

Peritonitis 

82 

Ligature.  Both 
ovaries 

5      „ 

Died,  3rd  day 

Crural  phlebitis  and  septicemia 

83 

Clamp 

16      „ 

4      ,, 

Recovered 

Married  1867.  Seven  children,  one  girl, 
six   boys— born    1868-69-70-71-73- 
78-79.  Miscarriages— Dec.  1879,  June 
1880  of  twins.    Now  pregnant  and 
well,  Nov.  1881 

84 

Clamp 

7     „ 

9      » 

Recovered 

Well  in  1881 

85 

Ligature  . 

40      „ 

5      „ 

Recovered 

Died  1866  of  pelvic  abscess  and  fecal 
fistula 

86 

Clamp  and  liga- 
ture 

12      „ 

4      „ 

Recovered 

Well  and  single  in  1872 

S7 

Clamp     . 

15      „ 

6      „ 

Recovered 

Died    1875,  eleven    years    after  ope- 
ration 

88 

Clamp 

29      „ 

4      „ 

Died,  114  hours 

Tubercular  peritonitis 

89 

Clamp 

14      „ 

3      „ 

Recovered 

No  report 

90 

Clamp     . 

59      „ 

6      „ 

Recovered 

Well  in  1881 

91 

Ligature . 

34      „ 

8      „ 

Died,  64  hours 

Peritonitis 

92 

3     „ 

Recovered 

Well  and  single  in  1881 

93 

Clamp 

18      „ 

6     ,. 

Recovered 

Well  and  widow  in  1872.     No  report 
since 

94 

5      „ 

Recovered 

Well  in  1870 

95 

Ligature  . 

25      „ 

6      „ 

Died,  44  hours 

Peritonitis 

96 

Ligature  . 

14      „ 

7      » 

Died,  67  hours 

Septicemia 

97 

Clamp 

16      „ 

4      „ 

Recovered 

Girl  born  since  operation.  Craniotomy 
necessary.    Well  in  1881 

98 

Clamp 

28      „ 

4      ,, 

Recovered 

Well  and  single  in  1871.    No  report 
since 

99 

Clamp  and  liga- 
ture.     Both 
ovaries 

4      „ 

Recovered 

Health  excellent  in  1881 

100 

Ligature  . 

12      „ 

4      „ 

Recovered 

Married  July  1868— no  child.     Died 
of  tuberculosis,  July  1872 

101 

Ligature  . 

20      „ 

8      „ 

Died,  4th  day 

Fibrinous  clot  in  heart  and  pulmonary 
artery 

102 

Ligature  . 

18       „ 

4       „ 

Died,  29th  day 

Jlironic  peritonitis 

103 

Clamp 

17      „ 

'I       ,i 

Recovered 

Cusband  died;     married     again;    two 
children   by  second   husband.      Died 
Of  bronchitis,  1879 

101 

348 


TABLE   OF   ONE   THOUSAND   CASES 


105 
106 

107 
108 
109 
110 

111 

112 


114 
115 
116 
117 

118 
119 
120 
121 

122 

m 

124 
125 


127 
128 
129 
130 

131 

132 

133 
134 

135 
136 
137 
138 
139 


Medical  Attendant 


Mr.  Savile,  Rotherham 
Hospital 


Mr.  Carden,  Worcester 
Dr.  Earnsbothani 
Hospital 
Dr.  De  Mussy 

Mr.  Square,  Plymouth 

Dr.  Greenhalgh  . 


Sir  T.  Watson      . 

Hospital       .... 
Mr.  Savory,  Stoke  Newington 
Hospital       .... 
Hospital       .... 

Hospital      .... 
Dr.  Crede,  Leipzig 
Dr.  Evans,  Hertford   . 
Mr.  Wright,  Nottingham  . 
Hospital       .... 

Hospital       .... 
Mr.  Forster,  Daventry 
Hospital      .... 

Hospital      .... 

Hospital  .... 

Hospital  .... 

Dr.  Farre  .... 

Hospital  .... 

Dr.  Whitehead,  Manchester 

Mr.  Hodgson 

Mr.  May,  Crosby. 
Dr.  Beatty,  Dublin 

Hospital       .... 
Dr.  Breslau,  Zurich    . 
Hospital      .... 
Hospital      .... 
Hospital       .... 

Dr.  Bullcn    .... 


Date 

of 

Operation 


1864  July 
„    July 

„  Oct. 

„  Nov. 

„  Nov. 

„  Nov. 

„    Nov. 

,,    Nov. 

„    Nov. 

„  Nov. 

„  Dec. 

,,  Dec. 

„  Dec. 

1865  Jan. 
„  Jan. 
„  Jan. 
„  Feb. 
„    Feb. 

„    Feb. 
„    Marcl 
,,    March 

„    April 

„  April 

,.  May 

„  May 

,,  June 

„    June 

„     June 

„    June 
„    June 

„  July 

„  July 

»  July 

»  July 

„  Aug. 

,.    Oct. 


Condition 


Single 
Single 

Married 
Single 
Married 
Married 

Single 

Single 

Single 

Single 
Married 
Single 
Single 

Single 

Single 

Married 

Single 

Single 

Married 
Married 
Single 

Married 

Married 
Married 
Married 
Single 

Married 

Single 

Married 
Married 

Married 
Married 
Married 
Married 
Married 

Married 


Adhesions 


None  . 

Omental 


Parietal.    Burst  cyst , 

Parietal 

None    .        .        .        . 

Omental 


Parietal 
None    . 


Omental  and  intestinal.    Burst 
cyst 

None 

Omental 

None 

None    .".... 


None 

Parietal  and  omental . 
Parietal  and  omental . 
Parietal       .... 
Parietal,  pelvic,  and  omental 

Parietal  and  omental . 

None 

None 


Omental 


Parietal 

Parietal  and  omental . 
Parietal  and  omental . 
Parietal 

Parietal,  omental,  and  intestinal 

None 


Parietal  and  omental . 
Parietal  and  intestinal 

Omental      .... 
Parietal  and  omental .        . 

None 

Parietal       .... 
Omental.    Pregnant  uterus 

Parietal  and  omental . 


OF   COMPLETED   OVARIOTOMY 


349 


Treatment  of 
Pedicle 

Weight  of 
Tumour 

Length 

of 
Incision 

Clamp 

11  pounds 

4  inches 

Clamp      . 

18      „ 

4      „ 

Ligature  . 

26     „ 

5      „ 

Clamp 

28      „ 

8      „ 

Clamp 

20      „ 

4      „ 

Ligature.  Both 
ovaries 

36      „ 

7      „ 

Clamp 

16     ,; 

5      „ 

Clamp 

15      „ 

4       „ 

Clamp 

50      „ 

10      „ 

Clamp 

35      „ 

9      „ 

Clamp 

20      „ 

5      ,, 

Clamp 

10      „ 

4       „ 

Ligature 

15      „ 

7      „ 

Clamp 

28      „ 

7      „ 

Clamp 

15      „ 

6      „ 

Clamp 

46      „ 

7      „ 

Clamp 

33      „ 

7      „ 

Clamp 

28      „ 

5      „ 

Clamp 

20      „ 

6      „ 

Clamp 

27      „ 

8      „ 

Clamp 

32      „ 

5      „ 

Clamp  and  liga- 
ture 

45      „ 

20      „ 

Clamp 

27      „ 

5      » 

Ligature  . 

23      „ 

8      „ 

Clamp 

27      „ 

5      „ 

Ligature  . 

30      „ 

5      „ 

Ligature.  Both 
ovaries 

23      „ 

7      „ 

Clamp 

60      „ 

4      „ 

Ligature  . 

33      „ 

5      „ 

Ligature.  Both 
ovaries 

5      „ 

Clamp 

8      „ 

Clamp 

48      „ 

8      „ 

5      „ 

Clamp 

75      „ 

5      „ 

Clamp.  Uterine 
ligatures 

28      „ 

4      „ 

Clamp 

Recovered 
Recovered 

Died,  11th  day 
Recovered 
Recovered 
Recovered 

Recovered 

Recovered 


Died,  3rd  day 

Recovered 
Recovered 
Died,  4th  day 
Recovered 

Recovered 
Recovered 
Recovered 
Recovered 
Recovered 

Died,  5th  day 

Recovered 

Recovered 


Died,  27  hours 

Recovered 
Recovered 
Recovered 
Recovered 

Died,  30  hours 

Recovered 

Died,  5th  day 
Recovered 

Died,  4th  day 
Recovered 
Recovered 
Died,  9th  clay 
Recovered 

Recovered 


Subsequent  History 

or 

Cause  of  Death 


Well  and  single  in  1872.  No  report 
since 

Married  May  1870 ;  no  children — 
swelling  on  right  side  of  abdomen. 
Well  in  1872.    No  report  since 

Septic  peritonitis 

No  report,  gone  away 

Well  in  1872.    No  report  since 

WeU  in  1872 ;  died  in  1879  of  abdominal 
disease 

Died  in  six  weeks  of  cancer 

Married  1865.  G-irls  born  1866,  1868, 
1869  ;  boy  July  1871  ;  two  children 
since — labours  natural.  "Well  in 
1881 

Exhaustion 

Well  and  single  in  1872 

No  report 

Septic  peritonitis 

Married  1872.  Three  girls  1873-74-78. 
Well  in  1881 

WeU  and  single  in  1881 

No  report 

Well  in  1881- 

Well  and  single  in  1881 

Recovered  after  second  ovariotomy  in 
1866 — died  1868  of  pneumonia 

Peritonitis 

Well  in  1881 

Married  June  1869 ;  two  children — 
labours  natural.  Well  in  1872.  No 
report  in  1881 

Exhaustion 

Died  in  1869  of  scirrhus  of  rectum 

No  report 

WeU  in  1881 

Died  of  some  other  disease  in  spring  of 
1870 


Well  in  1881 ;  married  in  1870.    Hus- 
band dead — no  child 

Septicsemia 

Very  well  in  1881 ;    no  child    since 
operation 

Peritonitis 

Very  weU  in  1881 

No  report ;  gone  away 

Peritonitis 

Well  in  1881 

Health  good  in   1872;    widow  since 
operation 


350 


TABLE  OF   ONE   THOUSAND   CASES 


141 
L42 


146 
147 

148 

149 

150 
151 
152 
153 
154 
155 
156 

157 
158 
159 
160 
161 
162 
163 

164 
165 
166 
167 
168 
169 
170 
171 
172 
173 

174 
175 

176 

177 


Medical  Attendant 


Dr.  Allen,  Leeds . 

Dr.  Walker,  Peterborough . 


Hospital 


Hospital 

Dr.  Martin,  Rochester 


Dr.  Tapson,  Clapham 
Hospital 


Dr.  Hope,  Boulogne 
Mr.  Fuller  . 


Hospital     . 

Hospital 

Dr.  Budd     . 

Hospital 

Mr.  Earle,  Brentwood 

Hospital 

Mr.  Baker,  Birmingham 


Hospital      . 

Dr.  West     . 

Hospital 

Mr.  Carden,  Worcester 

Dr.  Burkitt 

Hospital 

Hospital 


Dr.  Symonds,  Clifton 

Hospital 

Dr.  Priestley 

Hospital 

Mr.  Leggatt 

Dr.  Bowles,  Folkestone 

Mr.  Woodman 

Mr.  Roberts,  Buabon  . 

Mr.  Wrench,  Baglow  . 

Hospital 


Mr.  Haynes,  Walton  . 
Mr.  Yate,  Godalming 

Dr.  Budd,  Clifton 
Dr.  Drysdale,  R.A.      . 


Hospital 


Date 

of 

Operation 


18G5  Oct. 
„    Oct. 

„     Oct. 

„    Nov. 
„    Nov. 


„  Nov. 

„  Nov. 

„  Dec. 

„  Dec. 

„  Dec. 

„  Dec. 
1866  Jan. 

„  Jan. 

,,  Jan. 

„  Jan. 

„  Feb. 

„  Feb. 

„  Feb. 

„  March 

„  March 

„  March 

„  March 

„  March 

„  April 

„  April 

„  May 

„  May 

»  May 

„  May 

„  June 

„  July 

„  July 

„  July 

u  July 

»  July 

„  July 

„  July 

„  Aug. 


Age 


Condition 

Man-ied 
Married 

tingle 

Single 
Single 


Single 
MaiTied 

Married 

Married 

Single 

Single 

Single 

Single 

Married 

Married 

Single 

Single 

Married 

Married 

Single 

Single 

Single 

Single 

Single 

Married 

Married 

Married 

Single 

Single 

Single 

Married 

Married 

Man-ied 

Married 
Man-ied 

Man-ied 
Man-ied 

Single 


None 

Parietal  and  intestinal       .  ' 

Pariet.il 

Parietal 

None 

Parietal  and  omental . 
Parietal 

Broad  ligament  . 

Parietal 

None 

None 

Parietal 

Parietal  and  omental 

None 

Omental 

None 

Parietal 

Parietal,  omental  nnd  intestinal 
Parietal.    Cyst  suppurating 
None.    Burst  cyst 
Parietal,  omental  and  mesenteric 

Parietal 

None 

None 

Omental 

Parietal  and  omental 
Parietal  and  omental 

None 

Parietal  and  omental 

None 

Parietal 

Parietal  and  omental 

Parietal 

Parietal,  omental  and  intestinal 
Parietal  and  omental 

None 

None 

None 


OF   COMPLETED    OVAEIOTOMY 


351 


Treatment  of 
Pedicle 

Weight  of 
Tumour 

Length 

of 
Incision 

Result 

Subsequent  History 

or 

Cause  of  Death 

No. 
141 

Ligature  . 

24  pounds 

5  inches 

Recovered 

Very  well  in  1872 

Ligature     and 
cautery 

5      » 

Died,  46  hours 

Exhaustion 

142 

Clamp 

30      „ 

5      „ 

Recovered 

Very  well — married  since  operation  ; 
'expected  to  be  confined  in  Julyl872.' 
No  report  since 

143 

Clamp 

30      „ 

5      „ 

Recovered 

Very  well  in  1881.   Single ;    menses 
regular 

144 

5      „ 

Recovered 

Married  March  1869.  Boy  still-born  at 
five  months,  1869  ;  two  more  still- 
born since— girl   1871— boy  1875— 
labours  easy.    Well  in  1881 

145 

Ligature  . 

28      „ 

5      „ 

Recovered 

Died  of  pneumonia,  March  1866 

146 

4      „ 

Recovered 

Had  a  child  since  operation.    Well  in 
1881 

147 

Ligature.  Both 

34      „ 

5      ,, 

Died,  22nd  day 

Peritonitis 

148 

ovaries 

Clamp  and  liga- 
ture 

40     „ 

5      .. 

Recovered 

Recovered  after  second  ovariotomy,  in 
1876.    Well  in  1881 

149 

Clamp 

31      „ 

6      „ 

Recovered 

Married  1875.    Well  in  1881 

150 

Clamp 

24      „ 

5      » 

Recovered 

Died  of  cancer  of  rectum,  Feb.  1867 

151 

Clamp 

17      „ 

6     „ 

Recovered 

Well  and  single  in  1881 

152 

Clamp 

22      „ 

4      „ 

Recovered 

Married  since  ;  gone  away 

153 

Ligature  . 

16      „ 

4      „ 

Died,  7th  day 

Peritonitis  and  clot  in  heart 

154 

Clamp 

9      » 

8      „ 

Died,  12th  day 

Septicaemia — cancer 

155 

Clamp  and  liga- 
ture 

52      „ 

6     ,, 

Recovered 

Died  in  1880 

156 

Clamp     . 

20      „ 

6      „ 

Recovered 

WeU  and  single  in  1881 

157 

Clamp 

7     „ 

4      „ 

Recovered 

Well  in  1881— no  children 

158 

Clamp     . 

8      „ 

5      » 

Died,  25  hours 

Pyaemic  fever 

159 

Clamp 

30     „ 

6      „ 

Died,  26  hours 

Exhaustion 

160 

Ligature  . 

24      „ 

5      » 

Died,  35  hours 

Peritonitis 

161 

Clamp 

69      „ 

4      „ 

Died,  52  hours 

Pulmonary  embolism 

162 

Ligature . 

16      „ 

7     „ 

Recovered 

Well  and  single  in  1872.     No  report 
since 

163 

Clamp 

16      „ 

7     „ 

Died,  4th  day 

Peritonitis 

164 

Clamp 

14      „ 

8      ,, 

Recovered 

Health  good  in  1872.    No  report  since 

165 

Clamp 

25      „ 

5      » 

Recovered 

WeU  in  1881 

166 

Clamp 

25      „ 

8      „ 

Died,  4th  clay 

Peritonitis 

167 

Ligature  . 

16      „ 

5     » 

Recovered 

Well  and  single  in  1881 

168 

Clamp 

15      „ 

7     „ 

Recovered 

Health  good  in  1881 

169 

Cautery    . 

28      „ 

4      » 

Recovered 

WeU  and  single  in  1881 

170 

Cautery  . 

23      „ 

4      u 

recovered 

Health  good  in  1872.    No  report  since 

171 

Cautery   . 

15     „ 

7      „ 

Died,  4th  day 

Septicasmia 

172 

Cautery  and 
ligature 

17      ., 

7      „ 

Recovered 

WeU  in  1872  ;  husband  dead.    No  re- 
port since 

173 

Clamp 

28      „ 

8      „ 

Recovered 

WeU  in  1872 .    No  report  since 

174 

Ligature  . 

23      „ 

4      „ 

Recovered 

Girls  born  1869  and    1874;    labours 
natural.    WeU  in  1881 

175 

Clamp 

13     „ 

6     „ 

Recovered 

WeU  in  1881  ;  large  fibroid  uterus 

176 

;» 

25      „ 

■>      „ 

Recovered 

ChUd  bom  March  1868.    Well  in  1872. 
No  report  since 

177 

Clamp     . 

4      ,, 

Recovered 

Married   1809  ;   girls  born    1870    and 
1871  —  labours    natural.     Well  in 
1872.    No  report  in  1881 

178 

352 


TABLE   OF   ONE   THOUSAND   CASES 


17:1 

180 

181 

182 

183 
184 
185 
186 

187 

188 
189 
190 

191 

192 


194 
195 
196 
197 

198 
199 


201 
202 

203 
204 
205 

206 

•2117 
208 
209 
210 

211 

212 

213 

214 


Medical  Attendant 


Hospital 

Dr.  Woakes,  Luton    . 

Dr.  Playfair 

Mr.  Clifton,  Islington 


Dr.  Si 

Hospital 

Dr.  Arthur  . 

Dr.  Kingsley,  Stratford-on 

Mr.  Johnson,  Croydon 


Dr.  G-reani  . 

Dr.  Hassall,  Richmond 

Hospital 


Dr.  Monckton,  Maidstone 
Mr.  Freer,  Stourbridge 


Dr.  Traill 


Hospital 

Mr.  Turner  . 

Mr.  Love,  Wimbledon 

Hospital 


Dr.  Gream 
Dr.  Farre 


Mr.  Illingworth 
Mr.  Wakefield 


Hospital 

Dr.  Hhigston,  Plymouth 

Hospital 


Mr.  Shipman,  Grantham 

Dr.  Graily  Hewitt      . 

Hospital 

Hospital 

Mr.  Marsack,  Tunbridge  Wells 


Hospital 

Mr.  C.  Reade,  Clifton 

Hospital 
Mr.  Tapson  . 


Date 

of 

Operation 


1866  Aug. 

„    Aug. 

„    Aug. 

„    Aug. 

„  Oct. 

„  Oct. 

,,  Oct. 

„  Oct. 

„    Oct. 

„  Oct. 
„  Oct. 
„    Nov. 

„    Nov. 

„    Nov. 

„    Dec. 

„    Dec. 

„    Dec. 

„    Dec. 

1867  Jan. 

„  Feb. 
„    Feb. 

„    March 

„  March 
„    March 

„  March 
„  March 
„    March 

„  April 

„  April 

„  May 

„  May 

„  May 

„    May 


June 
June 


Married 

Single 

Married 

Married 

Single 
Married 
Married 
Married 

Single 

Single 

Married 

Married 

Married 

Single 

Married 

Married 
Married 
Married 
Married 

Married 
Married 

Married 

Single 
Single 

Married 

Single 

Single 

Married 

Married 

Single 

Married 

Married 

Married 

Single 

Widow 
Single 


Adhesions 


Parietal  and  omental . 

■  Parietal  and  omental  . 
Parietal,  omental  and  intestinal 
Parietal,  omental  and  intestinal 
None 


Parietal  and  intestinal 

Parietal 

None    .... 

Parietal 

Omental  and  intestinal 

Omental  and  intestinal 

Omental 

Broad  ligament  . 


None 


None  . 
Omental 
None    . 


None 

None 


None    . 
Omental 


None 


None 
None 


Parietal 
None  . 
Extensive 

Parietal 
Parietal 
Parietal 
Parietal 
None    . 


None 

Ruptured  adherent  cyst     . 

None 

Parietal,  omental  and  intestinal 


OF   COMPLETED    OVARIOTOMY 


353 


Treatment  of 
Pedicle 

"Weight  of 
Tumour 

Length 

of 
Incision 

Eesult 

Subsequent  History 

or 

Cause  of  death 

No, 

5  inches 

Recovered 

Weak  ;  otherwise  quite  well  in  1872. 
No  report  since 

179 

Clamp 

21  pounds 

4      „ 

Recovered 

Well  and  single  in  1872.    No  report 
since 

180 

Cautery  and 
ligature 

33      „ 

7     „ 

Convalescent 

Died  a  month  after  of  peritonitis  from 
an  accident 

181 

Clamp     . 

28      „ 

5      ,. 

Recovered 

Remained  well   tiU    1871,  when   she 
died  of  some  other  disease 

182 

Clamp 

28      „ 

5      » 

Recovered 

WeU  in  1874.    No  report,  1881 

183 

Clamp 

29      „ 

9      „ 

Recovered 

Well  in  1871.    No  report  since 

184 

Cautery   . 

18      „ 

7      „ 

Died,  5th  day 

Peritonitis 

185 

Cautery      and 
ligature 

36      „ 

6      „ 

Recovered 

Health  good  in  1881 

186 

Cautery      and 
ligature 

20       „ 

6      „ 

Recovered 

Harried  1869;  had  miscarriage  1871. 
WeU  in  1872.    No  report  since 

187 

Clamp      .        . 

14       .,' 

5      ,. 

Recovered 

WeU  and  single  in  1881 

188 

Ligature  . 

44       „ 

9      „ 

Died,  42  hours 

Peritonitis 

189 

Clamp 

24       „ 

4      „ 

Recovered 

Health    very    good  in    1881 ;   widow 
since  operation 

190 

Clamp 

23       „ 

4       ,, 

Recovered 

Very  well  in  1881 ;  slight  hernial  pro- 
trusion in  cicatrix 

191 

Clamp 

14       „ 

4      „ 

Recovered 

Harried   since  operation ;    girl  born 
1869— labour    lingering.      Well    in 
1881 

192 

Clamp  and  liga- 
ture 

32      „ 

6      „ 

Recovered 

Died  in  1877,  kidney  disease 

193 

Clamp 

22       „ 

10      „ 

Died,  33  hours 

Peritonitis 

194 

Clamp 

15      „ 

6      „ 

Died,  76  hours 

Septicaemia 

195 

Clamp 

28       „ 

5      ,) 

Died,  5th  day 

Pyasmic  fever 

196 

Cautery      and 
ligature 

12       „ 

4       „ 

Died,  4th  day 

Peritonitis 

197 

Clamp 

17       „ 

5      ,. 

Recovered 

Died  a  year  afterwards  of  renal  disease 

198 

Cautery      and 
ligature 

25       „ 

7      „ 

Recovered 

Well  in  1881 

199 

Clamp 

28       „ 

s     » 

Recovered 

Boys  born  1868   and    1870  — labours 
natural.    Well  in  1881 

200 

Cautery   . 

14       „ 

5      „ 

Recovered 

Well  in  1872 

201 

Cautery      and 
ligature 

16       „ 

5      ,, 

Recovered 

Harried   1871 ;   one  child  born  Hay 
1872 — labour  natural,  two  abortions 
since.    Well  1874 

202 

Clamp 

25       „ 

5      „ 

Recovered 

Health  good  in  1881 

203 

Cautery   . 

14       „ 

6      „ 

Recovered 

WeU  and  single  in  1881 

204 

Ligature       re- 
turned 

23       „ 

6      » 

Died,  20th  day 

Obstructed  intestine 

205 

Clamp 

32      „ 

5      „ 

Recovered 

Very  well  in  1881 

206 

Clamp 

14       „ 

6      „ 

Recovered 

Died  in  1870  of  anaemia 

207 

Clamp 

37       „ 

5      „ 

Recovered 

Well  and  single  in  1881 

208 

Clamp 

38       „ 

5       „ 

Recovered 

Well  in  1872.    No  report  since 

209 

("lamp 

18       „ 

5       „ 

Recovered 

Child  bom  1868.     Well  in  1872.     No 
report  since 

210 

Clamp 

14       „ 

5      „ 

Recovered 

Died  July    1871,  of    cardiac  disease, 
with  dropsy 

211 

Clamp 

42       „ 

5      „ 

Recovered 

Very  well  and   single  in    1872.    No 
report  since 

212 

Clamp 

52       „ 

4       ,, 

Recovered 

No  report 

213 

Clamp 

1.5       „ 

5       i) 

Died,  42  hours 

Exhaustion 

214 

A  A 


354 


TABLE    OF   ONE   THOUSAND   CASES 


No. 


215 
216 
217 

2  IS 
219 

220 
221 

222 
223 

224 

225 

226 
227 
228 
229 

2:50 

231 
232 


234 
235 
23C 
237 

238 
239 

24d 

241 

242 
213 
244 

245 

246 

247 


249 
250 
251 


Medical  Attendant 


Hospital 

Sir  G.   Burrows  . 

Dr.  Southey 

M.  Nelaton  . 

Dr.  Sharpe,  Norwood 

Hospital      .        . 

Hospital 

Dr.  Priestley 

Hospital 

Hospital 

Hospital       , 

Dr.  Symc-nds,  Clifton 
Dr.  Graseniann   . 
Mr.  Franks,  Sevenoaks 
Mr.  Wooluier 


Dr.  Bowles,  Folkestone 


Dr.  Budd,  Clifton 
Hospital 


Dr.  West 


Hospital 

Hospital 

Dr.  Whitehead,  Manchester 

Mr.  Kesteven 

Hospital 
Hospital 


Hospital 


Hospital 
Mr.  B.  P.  Youn< 
Dr.  De  Mussy 
Hospital 


Hospital 
Hospital 
Dr.  Clereland 


Hospital 

Hospital 
Hospital 
Hospital 


Mr.  Smith,  Battle 


Date 

of 

Operation 

Age 

1867  June 

52 

„ ,  June 

35 

„    June 

39 

„    June 

42 

„    June 

38 

»  July 

50 

„    July 

56 

„    July 

59 

»    July 

51 

„    July 

53 

.,    Aug. 

25 

„    Aug. 

41 

»    Aug. 

25 

„    Aug. 

27 

„    Oct. 

27 

„     Oct. 

52 

„    Oct. 

56 

„    Oct. 

40 

„    Oct. 

40 

„    Nov. 

42 

„    Nov. 

46 

„    Nov. 

51 

„    Nov. 

34 

„    Nov. 

23 

„    Nov. 

30 

„    Dec. 

25 

„    Dec. 

51 

„    Dec. 

40 

.  „    Dec. 

41 

„    Dec. 

23 

18G8  Jan. 

22 

„    Jan. 

48 

„    Jan. 

25 

„    Jan. 

34 

„    Jan. 

32 

„    Feb. 

33 

„    Feb. 

30 

„    Feb. 

50 

Condition 


Married 

Married 

Single 

Married 

Single 

Single 

Married 

Widow 

Married 

Married 

Married 

Widow 
Single 
Single 
Married 

Married 

Single 
Married 

Single 

Single 
Married 
Married 
Married 

Single 
Married 

Single 

Married 
Single 
Single 
Single. 

Single 

Married 

Single 

Single 

Married 

Single 

Single 

Married 


Adhesions 


Parietal 

None    .... 

Parietal 

Omental 

Parietal  and  intestinal 

Parietal 

None    .... 

None    .... 

None    .... 

Parietal  and  omental 

Pelvic  .... 

None    .... 
None   .... 
Parietal 
Parietal 

None  .... 

Parietal 
Omental 

None    .... 

Parietal 

Parietal  and  omental . 

Omental 

Parietal       . 

Parietal  and  omental . 
Parietal 

None   .... 

Intestinal    .        .        . 

Parietal  and  omental . 

Parietal 

Parietal  and  omental . 

None   .... 

None    .... 

Parietal 

None   .... 

Parietal  and  omental . 
Intestinal    . 
Parietal 

Parietal 


OF   COMPLETED    OVARIOTOMY 


355 


Treatment  of 
Pedicle 


Clamp 
Clamp 
Clamp 
Clamp 
Clamp 
Clamp 
Clamp 
Clamp 
Clamp 
Clamp 
Cautery  . 

Cautery  . 

Cautery  . 

Cautery   . 

Cautery      and 
ligatures 

Cautery      and 
ligatures 

Cautery  . 

Clamp 

Cautery      and 

ligatures 
Clamp 
Clamp 
Ligature 
Clamp 

Clamp 
Clamp 

Clamp 

Cautery 
Clamp 
Clamp 
Clamp 

Clamp 

Cautery      and 
ligatures 

Cautery      and 
ligatures 

Clamp 


Clamp 

Ligature 

Clamp 

Clam  p 


Weight  of 
Tumour 

Length 

of 
Incision 

17  pounds 

4  inches 

16       „ 

5      » 

26       „ 

5      „ 

28       „ 

8      „ 

19       „ 

5      » 

27       „ 

5      ,, 

5 

4      „ 

40       „ 

6      „ 

13       „ 

4       „ 

41       „ 

6      „ 

12      „ 

4      „ 

11      » 

4      „ 

13      „ 

4      „ 

16      „ 

5      „ 

40      „ 

5      „ 

18      „ 

4      „ 

6      „ 

4      „ 

32      „ 

5      „ 

18      „ 

4      „ 

30      „ 

5      „ 

15      „ 

5      „ 

9      » 

7      „ 

20      „ 

5      „ 

19      „ 

5      „ 

10      „ 

5      „ 

10      „ 

4      „ 

11      .. 

5      " 

16      „ 

5      » 

24      „ 

5      „ 

21      „ 

7      „ 

26      „ 

4      „ 

14      „ 

4      „ 

11      ., 

5      », 

25      „ 

5      „ 

46      „ 

7      „ 

11      ,. 

5      „ 

18      „ 

5      „ 

21      „ 

6      ■■ 

Eecovered 

Recovered 

Recovered 

Recovered 

Recovered 

Recovered 

Recovered 

Recovered 

Died,  8th  day 

Died,  8th  day 

Recovered 

Recovered 
Recovered 
Recovered 
Died,  51  hours 

Recovered 

Recovered 
Recovered 

Recovered 

Recovered 
Recovered 
Died,  13th  day 
Recovered 

Recovered 
Recovered 

Recovered 

Recovered 
Recovered 
Recovered 
Recovered 

Recovered 

Died,  5th  day 

Recovered 

Recovered 

Recovered 
Died,  4th  day 

Recovered 

Recovered 
A   A    2 


Subsequent  History 

or 

Cause  of  Death 


Well  in  1872.     No  report  since 

Well  in  1881 

Pretty  good  health  in  1881.     Single 

Very  well  in  1881 

Health  excellent  in  1881.    Still  single 

Died  Dec.  1868  of  delirium  tremens 

Well  in  1881 

Very  well  in  1881 

Peritonitis 

Peritonitis 

Very  well  in  1872.  Boys  born  1869, 
1870,  and  1872— labours  natural.  No 
report  since 

Very  well  in  1881 

Well  and  single  in  1881 

Well  and  single  in  1881 

Septicaemia 

Died  1879  of  paralysis 

Well  in  1881 

Very  well  in  1875.  Not  seen  since. 
Husband  dead.  No  child  since 
operation 

Well  and  single  in  1881 

Well  and  single  in  1881 

Well  in  1881 

Cardiac  embolism  and  carcinoma 

Well  in  1881.  Has  had  two  children 
since  operation 

Married — three  children — well  in  1881 

Boy  born  1869 — labour  lingering  but 
natural.    Well  in  1872 

Well  and  single  in  1872.  Believed  to 
be  dead  1881 

Very  well  in  1881 

Very  well  and  single  in  1881 

Well  in  1881 

Very  well.  Married  Jan.  1872,  and  was 
pregnant  in  May  1872 

Pretty  well  in  1872 ;  suffers  from 
dysmenorrhoea.    No  report  since 

Exhaustion 

Health  good.  Married  1870.  Girls 
born  1870  and  1872 — labours  natural. 
No  report  since 

Health  good  in  1872.  Married  June 
1869 ;  no  child 

No  report 

Peritonitis 

Married  1870— had  twins  1871— labour 
natural.    Well  in  1872 

Health  good  in  1881 ;  small  hernia 
through  cicatrix 


356 


TABLE   OF    ONE   THOUSAND    CASES 


253 

254 

255 
256 
257 
258 
259 
260 
261 
262 

263 
264 


2G6 
267 
268 
269 

270 


272 
273 


274 
275 


277 
278 
270 
280 

281 
282 

283 
284 
285 
286 


Medical  Attendant 


Hospital   .... 

Dr.  Buckall,  Chichester 

Mr.  Morris,  Edmonton 
Hospital  .... 
Hospital  .... 
Mr.  Nunn  .... 
Mr.  Crompton,  Birmingham 
Dr.  Tilt  .... 
Hospital  .  .  .  . 
Hospital      .... 


Hospital 
Dr.  B.  Ellis  . 


Hospital 


Hospital 

Mr.  Mason,  Surbiton 

Dr.  Pocock,  Brixton 

Hospital 

Hospital 


Hospital 


Dr.  Redlich,  Moscow 
Hospital 


Hospital 
Hospital 

Hospital 


Hospital  .... 
Mr.  Wright,  Clapham  Boad 
Hospital  .... 
Dr.  J.  Clarke 


Hospital 
Hospital 


Dr.  Morris    . 

Hospital 

Dr.  Grenser,  Dresden . 

Dr.  Roberts,  Manchester 


Hospital 


288  |  Hospital 


Date 

of 

Operation 


1868  March 

„  March 

„  March 

„  March 

„  March 

„  March 

„  March 

„  March 

„  April 

„  April 


April 
April 


May 


May 
May 
May 
May 
June 

June 

June 
June 

July 
July 

July 

July 
Aug. 
Oct. 
Oct. 

Oct. 
Oct. 

Oct. 
Oct. 
Oct. 
Oct. 

Oct. 
Oct. 


Condition 


Single 

Married 

Married 

Widow 

Single 

Married 

Married 

Single 

Widow 

Single 

Married 
Single 


Widow 

Married 

Married 

Single 

Single 

Married 

Widow 
Single 

Widow 
Married 

Married 

Married 
Single 
Single 
Married 

Widow 
Single 

Single 
Single 
Single 
Married 

Married 


Adhesions 


None 

Parietal  and  omental . 

None 

Omental 

Omental 

Parietal,  omental  and  intestinal 

None 

Parietal 

Parietal 

Parietal  and  omental 

Parietal 

Tarietal  and  omental 

Parietal 


None.    Ruptured  cyst 
Parietal,  intestinal,  and  pelvic  , 
Parietal  and  omental 

None 

None 

None 

Parietal 

Parietal       . 

Parietal  and  omental 

None 

Parietal  and  omental 

Parietal 

Parietal 

Parietal 

None 

Parietal  and  omental 
Parietal  and  omental 

Parietal  and  omental 

Parietal 

None 

Omental 

Parietal,  omental  and  intestinal 


45       Widow 


Parietal  and  omental 


OF   COMPLETED    OVARIOTOMY 


357 


1    Treatment  of 
Pedicle 

Weight  of 
Tumour 

Length 

of 
Incision 

6  inches 

Eesult 

Subsequent  History 

or 

Cause  of  Death 

No. 
253 

Clamp 

19  pounds 

Recovered 

Married  June  1868— had  child.    Well 
in  1872.    No  report  since 

Clamp 

20      „ 

5      „ 

Recovered 

Health  good  in  1869.    Girl  born  1870 
— labour'  natural 

254 

Clamp     . 

19      „ 

5      » 

Recovered 

Well  in  1872.    No  report  since 

255 

Clamp     . 

28      „ 

5      » 

Recovered 

No  report 

256 

Clamp      . 

19      „ 

5      „ 

Recovered 

Well  in  1872.    No  report  since 

257 

Ligature  . 

50      „ 

6      ,» 

Died,  48  hours 

Exhaustion 

258 

Clamp     .        . 

20      „ 

3      „ 

Recovered 

Well  in  1881 

259 

Clamp 

7      „ 

4      „ 

Recovered 

Well  in  1871.    No  report  since 

260 

Clamp 

18      „ 

4      „ 

Recovered 

Very  well  in  1872.    No  report  since 

261 

Clamp      .        . 

32      „ 

4      „ 

Recovered 

Married  in  April  1872.   Three  children 
1873-74-76.     Well  in  1881 

262 

Clamp 

21      „ 

4      » 

Recovered 

Died,  1877— disease  of  bladder 

263 

Pins  and  liga- 
tures —  both 
ovaries     re- 
moved 

30      „ 

5      » 

Died,  80  hours 

Peritonitis 

264 

Clamp  and  liga- 
tures —  both 
ovaries     re- 
moved 

32      „ 

5      .. 

Recovered 

Health  perfect  in  1881 

265 

Clamp 

25      „ 

5      .» 

Recovered 

Died  of  cardiac  dropsy,  Aug.  1869 

266 

Ligatures 

24      „ 

6      „ 

Died,  2  hours 

Collapse 

267 

Clamp 

26      „ 

5      „ 

Recovered 

Very  well  in  1881 ;  husband  died 

268 

Clamp 

17      „ 

5      „ 

Recovered 

Girl  born  1869.    Well  in  1872 

269 

Clamp      . 

20      „ 

4      „ 

Recovered 

Well  and  single  in  1872.    No  report 
since 

270 

Clamp 

13      „ 

4      „ 

Recovered 

In  good  health,  1874.    Gone  to  South 
America 

271 

Clamp 

31      „ 

5      » 

Recovered 

Died  9  years  after  operation 

272 

Clamp 

50      „ 

4      „ 

Recovered 

Well  and  single  in  1872.    Died  two  or 
three  years  ago— old  age 

273 

Clamp 

9      ,. 

5      „ 

Recovered 

No  report 

274 

Clamp 

15      „ 

4      „ 

Recovered 

Very  well  in  1872.     Girls  born  1869 
and  1870— labours  natural 

275 

Clamp 

28      „ 

5      „ 

Recovered 

Very  well  in   1872.      Girl  born  1870 
—  labour     easier     than     previous 
ones 

276 

Clamp 

12      „ 

4      „ 

Recovered 

Well  in  1872.    No  report  since 

277 

Clamp 

26      „ 

5      » 

Died,  3rd  day 

Septicaemia 

278 

Clamp 

17      „ 

5      „ 

Recovered 

Well  and  single  in  1881 

279 

Clamp 

15      „ 

4      „ 

Recovered 

Very  well  in  1872.     Boys  born  1869 
and  1871 — labours  natural 

280 

Clamp 

31      „ 

5      » 

Recovered 

Died  in  1879 

281 

Clamp 

26      „ 

8      „ 

Recovered 

Married  1874 — two  children.    Well  in 
1881 

£82 

Clamp 

19      „ 

5      „ 

Recovered 

Died,  October  1873,  of  phthisis 

283 

Ligature . 

9      ., 

4      „ 

Died,  42  hours 

Septicaemia 

284 

Cautery   . 

06      „ 

4       >i 

Recovered 

Well  in  1881 

285 

Clamp 

15      „ 

4      „ 

Recovered 

Very  well  in  1881  ;  no  child  since  ope- 
ration 

286 

Ligatures — 

both  ova    r 
removed 

23      „ 

5      „ 

Died,  23  hours 

Shock 

287 

Clamp     .       .  | 

33      „ 

6      „ 

Died,  so  hours 

Exhaustion 

288 

358 


TABLE   OF   ONE  THOUSAND   CASES 


Medical  Attendant 


289     Dr.  West 


Hospital 

Mr.  Oldham,  Brighton 

Mr.  Keele,  Southampton 

Dr.  Eansom,  Nottingham 

Dr.  Davies,  Holywell  . 

Hospital 

Hospital 

Dr.  A.  Farre 

Dr.  Attenburrow,  Jersey 

Hospital 

Sir  T.  Watson,  Bart. . 


Hospital 


Hospital 

Mr.  Bwen,  Wisbeach  , 
Dr.  Jackson,  Oxford  , 
Dr.  Gream  . 


Hospital 
Hospital 
Hospital 

Hospital 


Hospital 
Dr.  Leadam 
Hospi'al 
Hospital 
Dr.  Oldham 
Mr.  Squire  . 

Mr.  Stevens,  Christchurch 

Dr.  Livy,  Bolton 

Dr.  Bidley,  Canada     . 


Hospital 


Dr.  Braxton  Hicks 

Sir  W.  Jenuer,  Bart.  . 

Hospital      .... 

Dr.  Nethe,  Neuhaldensleben 
Dr.  Fitzpatrick  . 
Dr.  Quain    .... 
Sir  G.  Bui  rows  . 


Date 

of 

Operation 


Alt 


„  Nov. 

„  Nov. 

„  Nov. 

„  Nov. 

„  Nov. 

„  Dec. 

„  Dec. 

„  Dec. 

„  Dec. 
1869  Jan. 

„  Jan. 

„    Jan. 

„  Feb. 

„  Feb. 

„  Feb. 

„  Feb. 

„  Feb. 
„  Feb. 
„    Feb. 

„    March 

„  March 

„  April 

„  April 

„  April 

„  May 

„  May 

„  May 
„  May 
„    May 


Condition 


May 

22 

May 

39 

June 

27 

June 

24 

June 

42 

June 

30 

June 

50 

June 

47 

Married 


Single 

Married 

Single 

Married 

Married 

Single 

Married 

Single 

Single 

Single 

Single 

Married 

Married 
Single 
Married 
Single 

Married 

Widow 

Married 

Married 

Married 

Widow 

Single 

Single 

Single 

Single 

Single 
Single 
Married 

Single 

Married 

Married 

Married 

Married 
Single 
Single 
Married 


Adhesions 


Parietal  and  omental 


None 

Parietal  and  omental 

None 

None 

None 

Parietal       .... 
Parietal       .... 

None 

Parietal       .... 

None 

Parietal  and  omental . 

Parietal.    Ruptured  cyst  . 


Parietal 

None 

Parietal 

Parietal  and  pelvic    . 

Parietal,  omental,  and  intestinal 
None   .... 
Parietal  and  pelvic     . 


Parietal 


None.    Burst  cyst 

Omental 

Parietal  and  omental  . 

Parietal  and  mesenteric 

None   .... 

None.    Burst  cyst 

Parietal  and  omental . 
None  .... 
None   .... 


None 


Omental  and  pelvic 


None   .... 

Parietal  and  pelvic 

Intestinal    . 
Omental.    Burst  cyst 
Parietal  and  pelvic.    Burst  cyst 
Omental  and  intestinal 


OF   COMPLETED   OVARIOTOMY 


359 


Treatment 

of 

Pedicle 

Weight  of 
Tumour 

Length 

of 
Incision 

Result 

Subsequent  History 

or 

Cause  of  Death 

No. 

Clamp  and  lig£ 
tures  —  bot 

i-      58  pounds 

i 

6  inches 

Died,  29  hours 

Exhaustion 

289 

ovaries      re 
moved 

Clamp 

•       22       „ 

4      „ 

Died,  6th  day 

Peritonitis 

290 

Clamp 

•       33       „ 

G      „ 

Died,  45  hours 

Collapse 

291 

Clamp 

•       3G       „ 

5      „ 

Died,  34  hours 

Exhaustion 

292 

Ligatures 

•       30       „ 

4      „ 

Died,  40  hours 

Collapse 

293 

Clamp 

■       13       „ 

4      „ 

Recovered 

Very  well  in  1881 

294 

Clamp     . 

•       23       „ 

8      „ 

Recovered 

Well  in  1872.    No  report  since 

295 

Ligature  . 

7       „ 

5      „ 

Died,  56  hours 

Peritonitis 

296 

Clamp 

•       13       „ 

4      „ 

Died,  57  hours 

Pneumonic  congestion  and  embolism 

297 

Clamp     . 

22       „ 

6      „ 

Died,  54  hours 

Peritonitis 

298 

Cautery  . 

23       „ 

5      „ 

Recovered 

Died  in  1872 

299 

Clamp  and  liga 
tures 

28       „ 

7      „ 

Recovered 

Well  in  1872.    No  report  since 

300 

Pins  and  liga 
ture 

27       „ 

6      „ 

Recovered 

Died  Oct.  1869  of  some  other  disease 

301 

Clamp 

49       „ 

6      „ 

Recovered 

Health  excellent  in  1881 

302 

Clamp 

12       „ 

4      „ 

Recovered 

Very  weU  in  1872— still  single 

303 

Clamp 

21       „ 

7      » 

Recovered 

Well  in  1881 

304 

Clamp  and  liga 
tures 

-      22       „ 

7      „ 

Died,  26  hours 

Cardiac  embolism 

305 

Ligature  . 

39       „ 

7      „ 

Died,  4th  day 

Peritonitis 

306 

Clamp 

41       „ 

4      „ 

Recovered 

No  report 

307 

Clampandliga 
ture.      Both 

19       „ 

5      „ 

Recovered 

No  report 

308 

ovaries 

Pins  and  liga- 
ture 

36       „ 

9      » 

Died,  50  hours 

Coma  from  disease  of  heart 

309 

Clamp 

11       ,, 

6      „ 

Recovered 

No  report 

310 

Clamp 

13 

5      „ 

Recovered 

Very  well  in  1881 — husband  dead 

311 

Clamp 

12 

5      „ 

Died,  5th  day 

Intestinal  obstruction 

312 

Clamp 

13       „ 

5      „ 

Died,  7th  day 

Peritonitis 

313 

Clamp 

18       „ 

4      „ 

Recovered 

Well  and  single  in  1881 

314 

Clamp 

13       „ 

5      „ 

Recovered 

Married  1878,  one  child  1880.    Well  in 
1881 

315 

Clamp 

40       „ 

5      „ 

Died,  4th  day 

Peritonitis 

316 

Clamp 

9 

4       „ 

Died,  5th  day 

Peritonitis 

317 

Cautery   . 

13       „ 

4      „ 

Recovered 

Recovered  second  operation  July  1876. 
Well  in  1881 

31S 

Clamp  and  liga 
ture.      Botli 
ovaries 

H       „ 

4      „ 

Recovered 

Well  in   1872.    Stout  and  florid.    No 
report  since 

319 

Clamp  and  liga 

ture.      Both 

20        „ 

6      „ 

Recovered 

Died  April  1871.    Cardiac  dropsy 

320 

ovaries 

Clamp 

19 

5      „ 

Recovered 

Three  boys— 1873,  1874,  1S76.    Well  in 
1881 

321 

Ligatures.  Bot 
o  arii  i 

i     22       „ 

8       „ 

Died,  28  hours 

Collapse 

322 

Clamp 

20 

6      „ 

Recovered 

Health  very  good  in  1881 

323 

Clamp 

1  '■'•        „ 

4      „ 

Recovered 

Died  of  pleurisy,  Dec.  1809 

324 

Clamp     . 

9      .. 

5      „ 

Died,  1 7  hours 

Peritonitis 

325 

. 

20       „ 

6       „ 

Recovered 

Died  in  1878 

326 

360 


TABLE    OF    ONE    THOUSAND    CASES 


327 
328 
329 

330 

331 
332 
333 

334 

335 
336 

337 
338 
339 

340 

341 

342 

343 

31-1 

345 

346 
347 
348 

349 
350 

351 

352 

353 


355 
356 

357 


359 
360 


361 


Medical  Attendant 


Dr.  Greenhalgh  . 
Hospital 
Hospital 
Mr.  Bateman 

Mr.  Corner,  Poplar 
Mr.  Symonds,  Oxford 
Mr.  Clarke,  Huddersfleld 


Hospital 
Dr.  Gervis 
Hospital 


Hospital 

Dr.  Case,  Fareham 

Dr.  Rayner,  Stockport 

Hospital 
Hospital 


Hospital 


Dr.  Ramskill 
Hospital 


Mr.  Crompton,  Birmingham 


Dr.  Syinonds,  Clifton 

Hospital 

Dr.  West      . 


Hospital 
Hospital 

Sir  J.  Alderson    . 

Mr.  Cockcroft,  Darlington 

Dr.  Priestley 


Hospital 


Sir  W.  Jenner,  Bart. 

Hospital 

Hospital 


Mr.  Beckingscale,  Newport 

Dr.  Evans,  Birmingham     . 
Hospital       .... 


Mr.    Tweddcll,      Houghton-le- 
Spring 


Date 
of 

Operation 


1869  June 

„  June 

„  June 

„  Aug. 

„  Aug. 

»  Aug. 

„  Sept. 

„  Oct. 

„  Oct. 

„  Oct. 

„  Nov. 

„  Nov. 

„  Nov. 

„  Nov. 

„  Nov. 


„    Dec. 
Dec. 

1870  Jan. 

„  Jan. 
,,  Jan. 
„    Jan. 

„    Jan. 

„    Feb. 

„  Feb. 
„  Feb. 
„    Feb. 


March 


March 
March 
April 

April 

April 
April 


„    April 


A.ge 


Condition 


Married 
Married 
Married 
Married 

Single 
Single 
Single 

Single 
Single 
Married 

Single 
Single 
Married 

Married 

Single 

Single 

Married 
Married 

Single 

Single 

Married 

Single 

Single 
Widow 

Single 

Married 

Single 

Single 

Widow 
Married 
Married 

Married 

Single 
Married 


Married 


Omental  &  parietal.    Burst  cyst 

None 

Parietal  and  omental 
Omental.  Burst  cyst.  Pregnancy 

Parietal,  omental  and  intestinal 

None 

None 

None 

None 

None.    Burst  cyst 

Parietal  and  omental . 

None 

None 

Parietal  and  intestinal 
Intestinal 

None 

Omental 

Omental  and  intestinal 

Pelvic  ...... 

Parietal       ..... 

Parietal  and  omental . 

To  caecum 

Omental  and  parietal . 
Parietal 

None 

None 

None 

Omental 

Omental 

None 

None 

Omental  and  intestinal 

Omental,  intestinal,  and  parietal 
Omental      .  .        .        . 


OF    COMPLETED-  OVARIOTOMY 


361 


Treatment 

of 

Pedicle 

Weight  of 
Tumour 

Length 

of 
Incision 

Result 

Subsequent  History 

or 

Cause  of  Death 

No. 
327 

Clamp     .        . 

23  pounds 

6  inches 

Died,  3rd  day 

Peritonitis 

Ligature  • 

18       „ 

4      „ 

Died,  3rd  day 

Obstructed  intestine 

328 

Clamp     • 

23       „ 

6      „ 

Recovered 

Child  (boy)  born  Feb.  1870 

329 

Clamp 

37       „ 

7      „ 

Recovered 

Child  born,  Feb.  1870.    Died  of  cancer 
of  uterus,  March  1871 

330 

Clamp 

22       „ 

6      „ 

Recovered 

Died,  Dec.  1869,  of  diffuse  carcinoma 

331 

Clamp 

22       „ 

5      „ 

Recovered 

Well  in  1881 

332 

Clamp 

6       ,, 

4      „ 

Recovered 

Married  1870.    Boy  born  1871— labour 
easy.    No  report  since 

333 

Clamp 

17       „ 

4      „ 

Recovered 

No  report 

334 

Clamp 

6      „ 

4      „ 

Recovered 

Well  in  1881.    Still  single 

335 

Clamp  and  liga- 
ture 

20      „ 

6      „ 

Recovered 

Died  June  1872.    Re-growth  of  ova- 
rian tumour.    Amyloid  kidneys 

336 

Clamp 

21      „ 

4      „ 

Recovered 

Well  and  single  in  1881 

337 

Clamp 

16      „ 

3     „ 

Recovered 

Well  and  single  in  1872 

338 

Clamp 

21      „ 

4     „ 

Recovered 

Health  fair  in  1881— no  child  since 
operation 

339 

Clamp 

24      „ 

6     „ 

Died,  26  hours 

Collapse 

340 

Ligature  . 

19      „ 

4      „ 

Recovered 

Well  and  single  in  1872.    No  report 
since 

341 

Clamp  and  liga- 
ture 

14      „ 

4      „ 

Recovered 

Health  excellent  in  1872— still  single 

342 

Clamp 

16      „ 

4     „ 

Recovered 

Very  well  in  1881 

343 

Cautery      and 
ligature 

13      „ 

6     „ 

Recovered 

Died— return  of  disease  1871 

344 

Clamp  and  liga- 
ture 

13      „ 

5     ,, 

Recovered 

Married  Oct.  1870— child    born    Oct. 
1871— well  in  1881 

345 

Clamp 

24      „ 

5      » 

Recovered 

Well  and  single  in  1881 

346 

Clamp 

23      „ 

5      „ 

Recovered 

Died  1873 

347 

Clamp  and  liga- 
ture. I  Both 

12      „ 

3     „ 

Recovered 

Well  and  single  in  1881 

348 

ovaries 

Clamp 

33      „ 

4     „ 

Died,  4th  day 

Peritonitis 

349 

Clamp  and  liga- 
ture 

23      „ 

5      » 

Died,  39  hours 

Peritonitis 

350 

Clamp 

16      „ 

4      >, 

Recovered 

Health  very  good,  married  June  1871. 
Well  in  1881 

351 

Clamp 

28      „ 

4      „ 

Recovered 

Health  excellent  in  1872.    No  report 
since 

352 

Clamp  and  liga- 
ture.     Both 

18      „ 

4      „ 

Died,  5th  day 

Peritonitis 

353 

ovaries 

Clamp 

33      „ 

8     „ 

Recovered 

Married  1876— children,  girls.    Died  of 
consumption  1880 

354 

Ligature  . 

42      „ 

6      „ 

Died,  6th  day 

Septicaemia 

355 

Clamp 

11      „ 

4     „ 

Died,  4th  day 

Septicaemia 

35fi 

Clamp 

17      „ 

6      „ 

Recovered 

Health  very  good  in  1872— alive  in 
1881 

357 

Clamp  and  liga- 
ture 

35      „ 

6      „ 

Died,  18th  day 

Exhaustion 

358 

Clamp 

33      „ 

6      ,, 

Recovered 

Well  and  single  in  1881 

359 

Clamp 

29      „ 

6     ». 

Recovered 

Health  good  in  1881,  has  had  several 
miscarriages  both  before  and  since 
operation,  and  two  boys  1874  and 
1876 

360 

Clainp 

22 

o     ,. 

Recovered 

Well  in  1881 

361 

362 


TABLE  OF    ONE    THOUSAND    CASES 


No. 


Medical  Attendant 


Hospital 

Sir  W.  Gull,  Bart.       . 

Mr.  Barkway,  Bungay 

Hospital 

Hospital 


Dr.  Kinnear,  Malmesbury 

Dr.  Miller,  Blackheath 

Hospital 

Hospital 

Dr.  Welch,  Southampton 

Dr.  Collyer,  Enfield    . 

Dr.  Unna,  Hamburgh 
Hospital 


Hospital 
Hospital 


Mr.  Pyne,  Eoyston 
Hospital 


Dr.  Cole,  Bath    . 

Dr.  West     . 

Dr.  Swain,  Birmingham 


Hospital 

Mr.  Belcher,  Burton  . 

Mr.  Godson 
Hospital 

Mr.  Roberts,  Portmadoc 
Dr.  Orsborne,  Bittern 

Dr.  Smith,  Weymouth 


Hospital 

Mr.  Gibson,  Norwich 

Hospital 

Hospital 

Hospital 

Dr.  Prince  . 

Dr.  Smith,  Weymouth 

Hospital 


397    Mr.  Morris.  Edmonton 


Date 


1870  April 

„  May 

„  May 

„  May 

„  May 

„  May 

„  May 

„  May 

,,  June 

„  June 

„  June 

„  June 

„  June 

„  June 

»  July 

„  July 

.i  July 

»  July 

„  Aug. 

»  Aug. 


Aug. 

Aug. 
Oct. 

Oct. 
Oct. 

Oct. 

Oct. 

Oct. 
Oct. 
Oct. 
Nov. 
Not. 
Nov. 
Nov. 

Nov. 


Age 


Condition 


Married 
Widow 

Married 
Married 
Single 

Single 

Married 

Married 

Married 

Married 

Married 

Married 
Single 

Married 
Married 

Married 
Single 

Single 
Single 
Single 

Married 

Single 

Widow 
Single 

Married 
Widow 


Married 

Single 

Married 

Married 

Single 

Single 

AVidow 

Single 

Married 


Adhesions 


Omental 
None    . 


Parietal  and  omental . 

Parietal 

Parietal  and  omental , 


None  . 

Parietal 

Parietal  and  omental . 

None   . 

None   . 


None 


Omental  and  pelvic 
None    . 


Parietal 

Parietal  and  omental 


None    . 
Omental 

None  . 
Omental 
None    . 

Omental 


Parietal 
Omental 


None    . 
Parietal 


Parietal 


Parietal 

None.    Burst  cyst 

Parietal 

None   .        .        .        , 

Parietal 

None    . 

Parietal  and  omental 

None.    Burst  cyst 


OF    COMPLETED    OVARIOTOMY 


363 


Treatment  of 
Pedicle 


Ligature  . 
Clamp 

Clamp 
Clamp 
Ligature  . 

Clamp 
Clamp 
Clamp 
Clamp 
Clamp 

Clamp 

Ligature  . 
Clamp 

Clamp 
Clamp 


Clamp     . 

Clamp  and  liga- 
ture. Both 
ovaries 

Clamp 

Clamp 

Clamp 

Clamp 

Clamp 

Clamp 
Clamp 

Clamp 
Clamp 

Clamp  and  liga- 
ture. Both 
ovaries 

Clamp 


Clamp 
Clamp 
Clamp 
Clamp 
Clamp 
(  lamp 
1  lamp 


Ligature 


Weight  of 
Tuniour 


6  pounds 
21      „ 


Length 

of 
Incision 


5  inches 
5      „ 


Besult 


Recovered 
Recovered 

Recovered 
Died,  3rd  day- 
Recovered 

Recovered 
Recovered 
Recovered 
Died,  32  hours 
Recovered 

Recovered 

Recovered 
Recovered 

Recovered 
Recovered 

Recovered 
Died,  4th  day 

Recovered 
Recovered 
Recovered 

Recovered 

Recovered 

Recovered 
Recovered 

Recovered 
Recovered 


Recovered 

Recovered 

Died,  35  hours 

Recovered 

Recovered 

Recovered 

Recovered 

Recovered 

Recovered 


Subsequent  History 

or 

Cause  of  Death 


No  report 

Recovered  after  second  ovariotomy 
1878.    Well  in  1881 

Health  good  in  1881 

Hyperpyrexia 

WeU  and  single  in  1872.  Second 
operation  in  1875.  Married  1876 — 
■well  in  1881 

Well  and  single  in  1881 

WeU  in  1872.    No  report  since 

Health  very  good  in  1872 

Pneumonic  congestion 

Health  good  in  1881 ;  no  child  since 
operation 

Girl  born  July  18  71.  Verywellinl872. 
No  report  since 

Died  in  1881 — asthma 

Well  and  single  in  1872.  No  report 
since 

Boy  born,  July  1873.    No  report  since 

Health  good  in  1872,  husband  dead. 
Remarried — became  pregnant.  Not 
heard  of  since 

Health  good  in  1872.    No  report  since 

Peritonitis 


"Very  well  and  single  in  1881 

Well  and  single  in  1881 

Very  well  and  single  in  1872.  No  report 
since 

Health  good  in  1872,  husband  dead.  No 
report  since 

Married  1872— boy  born  1873.  WeU 
in  1874 

Health  good  in  1872.    No  report  since 

Since  mai-ried  —  child  in  1875 ;  in 
1877  tumour  of  breast.  No  report 
since 

Died  in  1877 — kidney  disease 

Health  very  good  in  1872.  No  report 
since 

Well  and  single  in  1881 


Twins,  girl  and  boy,  born  July  1872  ; 
girl  in  1874.    Well  in  1881 

Well  and  single  in  1881 

Exhaustion 

Health  excellent  in  1881 

No  report 

Died  of  bronchitis,  May  1871 

I  Icalth  excellent  in  1881 

Married  1*77— girl  1878,  boy  1880. 
Well  in  1881 

At  end  of  187]  cicatrix  save  way,  col- 
loid fluid  escaped,  and  continued  till 
i  he  dii  d  early  in  1872 


364 


TABLE   OF   ONE   THOUSAND   CASES 


398 
399 

■100 
40] 

402 

403 

404 
405 
406 

407 

408 

40!) 


411 
412 

413 

414 
415 
416 

417 
41S 
419 

420 
421 

422 
423 
424 
425 
426 
427 

428 
42!i 
430 
431 
432 
433 

434 
435 


Medical  Attendant 


Hospital 
Mr.  Goddard 

Dr.  Thetford 

Mr.  Yate,  Godalming 


Mr.  Aikin 


Hospital 


Dr.  Druitt  . 
Dr.  "Webb    . 
Dr.  Sieveking 
Hospital 


Dr.  Chepmall 
Dr.  Webb    . 


Hospital 


Mr.  Weekes,  Hurstpierpoint 
Hospital 


Hospital      .        . 

Hospital 

Mr.  Butler,  Guildford 

Mr.  Scrase,  Lewes 

Hospital 

Hospital 

Dr.  Ross 


Hospital      . 
Dr.  Mayer,  Berlin 


Hospital 

Hospital      .        . 

Dr.  Greenhalgh  . 

Mr.  Fouracre,  Hornsey 

Hospital 

Dr.  Schetelig,  Hamburgh 

Dr.  Jackson,  Southsea 

Hospital 

Hospital 

Dr.  Ronayne,  Youghal 

Hospital 

Hospital 


Professor  Winkel,  Bostock 
Dr.  Bell       . 


Date 

of 

Operation 


1870  Dec. 
„  Dec. 

„  Dec. 

1871  Jan. 

„  Jan. 

„  Jan. 

„  Jan. 

„  Jan. 

„  Feb. 

„  Feb. 

„  Feb. 

„  Feb. 

„  March 

„  March 

„  March 

„  March 

„  April 

„  April 

„  April 

„  April 

„  April 

„  May 

„  May 

„  May 


May 
May 
June 
June 
June 

July 
July 
July 
July 
July 
July 

Aug. 
Aug. 


Condition 


Married 
Married 

Married 
Married 

Married 

Married 

Single 
Married 
Single 
Married 

Single 
Single 

Married 

Single 
Single 

Single 

Single 

Single 

Married 

Married 

Single 

Married 

Married 
Married 

Single 

Single 

Married 

Single 

Married 

Married 

Single 

Married 

Married 

Siugle 

Married 

Married 

Married 
Married 


Adhesions 


Parietal,  omental,  and  intestinal 
None.    Pregnant 

Parietal.    Burst  cyst . 
Parietal 

Parietal 

Omental  and  mesenteric    . 

None    ...... 

Parietal.    Cyst  suppurating 
None.    Burst  cyst 
Parietal       .  . 

Parietal 

None 

Omental 

Omental       ..... 
Parietal 

Parietal 

Parietal       .        .        .        .        • 

Omental 

Parietal.    Burst  cyst 

Parietal  and  omental 

None 

Omental        and        intestinal. 
Pregnancy 

Parietal  and  omental . 

Parietal 

Parietal  and  omental . 

Parietal 

None    ...... 

None 

Omental 

Parietal  and  mesenteric    . 

None 

Parietal  and  omental . 

None 

None 

Parietal 

None 

None 

Parietal 


OF   COMPLETED    OVARIOTOMY 


365 


Treatment  of 
Pedicle 

Weight  of 
Tumour 

Length 

of 
Incision 

Result 

Subsequent  History 

or 

Cause  of  Death 

No. 

Clamp     .        • 

66  pounds 

8  inches 

Recovered 

Very  well  in  1872.    No  report  since 

398 

Clamp     . 

15      „ 

5       „ 

Recovered 

Child  born  seven  months  after  opera- 
tion.   Four  children  since  operation 
1871-73-76-78.    Very  weU  in  1881 

399 

Clamp 

28      „ 

5      „ 

Recovered 

One  child  in  1876.    "WeU  in  1881 

400 

Clamp     .        . 

17      „ 

5      .» 

Recovered    ' 

Health  very  fair  in  1872.    No  report 
since 

401 

Clamp  and  liga- 
ture 

15      „ 

5      „ 

Recovered 

Girl  born  1873.    WeUin  1881 

4.2 

Clamp  and  liga- 
ture 

6      „ 

5      „ 

Recovered 

Health  very  fair  in  1881.    Asthma  of 
long  standing 

403 

Ligature  . 

20      „ 

5      ,. 

Recovered 

Died  1880  of  bronchitis 

404 

Clamp     . 

19      „ 

5      „ 

Recovered 

Very  weU  in  1881 

405 

Clamp      , 

21      „ 

5      H 

Recovered 

Well  and  single  in  1881 

406 

Clamp     . 

35      „ 

5      „ 

Recovered 

Children  born  in  1872-77-79.    WeU  in 
1881 

407 

Clamp 

16      „ 

5      i. 

Recovered 

WeU  in  1881 

408 

Clamp 

4      „ 

Recovered 

Married  Sept.  1875— children  1877-78- 
81 ;  last  born  Sept.  24,  1881.    WeU 
Nov.  1881 

409 

Clamp 

35      „ 

5      „ 

Recovered 

SmaU  hernia  near  cicatrix.    Girl  born 
Jan.  1872— boy  in  July  1874.    Well 
in  1881 

410 

Clamp 

13      „ 

5      „ 

Recovered 

WeU  and  single  in  1881 

411 

Clamp 

23      „ 

5      » 

Recovered 

Died  April  1872  of  acute  rheumatism 
and  endocarditis 

412 

Clamp 

6      » 

4      „ 

Died,  5th  day 

Septicaemia 

413 

Cautery  . 

39      „ 

5      „ 

Recovered 

Died  in  1872  of  bronchitis 

414 

Clamp 

7      „ 

4      „ 

Died,  3rd  day 

Exhaustion 

415 

Ligature .        . 

34      „ 

6      ., 

Recovered 

Died  April  1873 

416 

Clamp 

24      „ 

5      i» 

Recovered 

Boy  in  1874.    Health  good  in  1881 

417 

Ligature . 

7      „ 

4      „ 

Recovered 

AUve  in  1881,  phthisical 

418 

Ligature  . 

32      „ 

5         !. 

Recovered 

Child  born  Dec.  1871,  another  1877. 
Alive  but  ill  in  1881 

419 

Clamp 

22      „ 

5      „ 

Died,  13th  day 

Pleuritic  effusion 

420 

Clamp  and  liga- 
ture.     Both 
ovaries 

19      „ 

5      » 

Recovered 

Well  in  1872.    No  report  since 

421 

Clamp 

19      „ 

4      „ 

Recovered 

WeU  and  single  in  1881 

422 

Clamp 

42      „ 

6      „ 

Died,  5th  day 

Septic  peritonitis 

423 

Clamp 

33      „ 

6      i) 

Died,  32  hours 

Exhaustion 

424 

Clamp 

19      „ 

6      „ 

Recovered 

Health  very  good  in  1881.    Still  single 

425 

Clamp 

18      „ 

7      ,. 

Died 

Went  home,  but  died  25  days  after 

426 

Ligature.  Both 
ovaries 

9      ■> 

Died 

Peritonitis 

427 

Ligature  . 

5      „ 

Recovered 

Well  and  single  in  1881 

428 

Clamp 

30      „ 

6      ,, 

Recovered 

Well  in  1872.    No  report  since 

429 

Clamp 

17      „ 

5      „ 

Recovered 

Quite  well  in  1881 

430 

Clamp 

22      „ 

4      » 

Recovered 

Well  in  1881 

431 

Clamp 

25      „ 

6      ii 

Recovered 

Died  of  heart  disease  1873 

432 

Clampanrl  liga- 
ture.     Both 
ovaries 

21      „ 

5      „ 

Recovered 

Died  Dec.  1871  of  malignant  disease 

43:) 

Clamp 

12      „ 

5      „ 

Recovered 

Well  in  1881.    Husband  dead 

434 

B      ., 

Recovered 

Boy  born  1873.    Husband  dead.    Very 
well  in  1881 

435 

366 


TABLE   OF    ONE   THOUSAND   CASES 


436 
437 

4i!S 
139 

44  0 

411 

442 
443 
444 
445 
446 
447 
448 
449 
450 
451 
452 

453 
454 
455 
456 

457 
458 

459 
460 
461 
462 
463 
464 
465 
466 
467 
468 

469 
470 
471 
472 
473 
474 
475 
476 


Medical  Attendant 


Mr.  Barlow 
Dr.  Boddaert,  Ghent . 
Mr.  Ticehurst,  Hastings    . 
Hospital      .... 

Professor  Schwartz,  Gbttingen 
Hospital 

Mr.  Baker,  Birmingham 

Hospital 

Dr.  Farre    . 

Dr.  Budd,  Clifton 

Dr.  Pirrie,  Belfast 

Mr.  Marriott,  Leicester 

Hospital 

Dr.  Lyon,  Clifton 

Mr.  Roughton,  Kettering 

Mr  Biggall. 

Hospital 

Hospital 
Hospital 
Hospital 
Hospital 

Sir  J.  Alderson 

Dr.  Turner,  Minchinhampton 

Hospital 

Mr.  Bell,  Rochester    . 

Mr.  T.  H.  Hill     . 

Dr.  Smith    . 

Mr.  Turner,  Berniondsey 

Dr.  Stewart,  Whitby  . 

Hospital 

Mr.  Pollard,  Torquay  . 

Dr.  Powne,  Swindon  . 

Hospital 


Hospital 
Hospital 
Hospital 
Hospital 
Hospital 
Hospital 
Hospital 
Hospital 


Hospital 


Date 

of 

Operation 

A-ge 

1871  Aug. 

41 

„  Aug. 

52 

,.  Aug. 

22 

„  Aug. 

32 

„  Aug. 

23 

„  Oct. 

41 

„  Oct. 

32 

„  Oct. 

42 

„  Oct. 

50 

„  Nov. 

30 

„  Nov. 

40 

„  Nov. 

42 

„  Nov. 

27 

„  Nov. 

29 

„  Nov. 

42 

„  Nov. 

56 

,,  Dec. 

27 

„  Dec. 

34 

„  Dec. 

40 

,,  Dec. 

21 

„  Dec. 

28 

„  Dec. 

60 

1872  Jan. 

27 

„  Jan. 

17 

,,  Jan. 

60 

„  Jan. 

55 

„  Jan. 

53 

„  Jan. 

46 

„  Jan. 

48 

„  Feb. 

22 

„  Feb. 

46 

„  Feb. 

57 

„  Feb. 

23 

„  Feb. 

41 

„  Feb. 

44 

„  Feb. 

48 

„  Feb. 

44 

„  March 

51 

„  March 

40 

„  March 

32 

„  March 

29 

,,  March 

50 

Condition 


Married 
Married 
Single 
Single 

Single 
Married 

Single 

Single 

Married 

Single 

Married 

Married 

Single 

Single 

Married 

Married 

Married 

Single 
Married 
Single 
Single 

Married 
Married 

Single 

Single 

Married 

Married 

Married 

Married 

Married 

Married 

Married 

Married 

Single 

Single 

Married 

Married 

Single 

Married 

Single 

Married 


Married 


Adhesions 


Omental  and  mesenteric    . 

Parietal  and  pelvic     . 

None 

Parietal   and  omental.     Burst 
cyst 

None 

None 

None.    Burst  cyst 

None 

None 

None  

None 

None 

None 

None 

None 

Parietal.    Cyst  suppurating 
None 

None 

Parietal 

None 

None 

Intestinal  and  mesenteric  . 
Parietal 

Parietal  and  omental . 

Parietal  and  intestinal 

Parietal  and  pelvic 

Parietal,  omental,  and  intestinal 

None.    Burst  cyst 

Omental  and  pelvic     . 

None 

Parietal,  omental,  and  intestinal 

Parietal 

None.    Burst  cyst 

None 

None 

Parietal  and  omental . 

None 

Parietal  and  omental .        . 
Omental.    Burst  cyst. 

Omental 

Omental.    Pregnancy 


None.    Burst  cyst 


OF   COMPLETED   OVARIOTOMY 


36: 


Treatment  of 
Pedicle 

Weight  of 
Tumour 

Length 

of 
Incision 

Result 

Subsequent  History 

or 

Cause  of  Death 

No. 
436 

Ligature  . 

15  pounds 

5  inches 

Recovered 

Well  in  1872.    No  report  since 

Clamp 

33      „ 

6      „ 

Recovered 

Well  in  1881 

437 

Clamp 

8      „ 

4      „ 

Recovered  _ 

Well  and  single  in  1881 

438 

Ligature  . 

6      „ 

Died,  5  hours 

Collapse 

439 

Clamp 

13      „ 

4      „ 

Recovered 

Health  very  good  in  1872.    Still  single 

440 

Ligature.  Both 
ovaries 

37      „ 

6      „ 

Died,  3rd  day 

Pulmonary  embolism 

441 

Clamp 

11      „ 

5      „ 

Recovered 

Well  and  single  in  1881 

442 

Clamp 

23      „ 

4      „ 

Recovered 

Well  in  1881 

443 

Clamp 

28      „ 

4      „ 

Died,  7th  day- 

Septicaemia 

444 

Clamp 

8      „ 

5      » 

Recovered 

Well  and  single  in  1881 

445 

Ligature  . 

24      „ 

5      „ 

Recovered 

Died  in  1873 

446 

Clamp 

23      „ 

4      „ 

Recovered 

Well  in  1881 

447 

Clamp 

8      „ 

4      „ 

Died,  5th  day 

Septicaemia 

448 

Ligature  . 

18      „ 

4      „ 

Died,  5th  day 

Hyperpyrexia  and  pericarditis 

449 

Clamp 

15      „ 

5      „ 

Died,  23  hours 

Exhaustion 

450 

Clamp 

49      „ 

8      „ 

Died,  26  hours 

Septicaemia 

451 

Clamp 

35      „ 

6      „ 

Recovered 

Three  children,  1872-73-75.    Married 
second  time  1880.    Well  in  1881 

452 

Clamp 

11      „ 

5      „ 

Died,  4th  day 

Septicaemia 

453 

Clamp 

51      „ 

6      „ 

Recovered 

Remains  well  in  1881 

454 

Clamp 

16      „ 

5      „ 

Recovered 

Married  1878.    Well  in  1881 

455 

Pin   and  liga- 
ture 

10      „ 

5      „ 

Recovered 

Well  in  1872.    No  report  since 

456 

Clamp 

15      „ 

6      „ 

Recovered 

WeR  in  1881 

457 

Clamp 

22      „ 

6      „ 

Recovered 

Remains   well   1872.      No   report  in 
1881 

458 

Clamp 

16      „ 

5     „ 

Recovered 

No  report  since  1872 

459 

Clamp 

33      „ 

6      „ 

Recovered 

Died  in  March 

460 

Clamp      .       . 

10      „ 

4      ,, 

Recovered 

Remains  well  1872.    No  report  since 

461 

Clamp 

18      „ 

5      „ 

Recovered 

No  report  since  1872 

4G2 

Clamp 

18      „ 

4      „ 

Recovered 

Remains  well  in  1881 

463 

Clamp 

41      „ 

6      „ 

Died,  3rd  day 

Exhaustion 

464 

Clamp 

24      „ 

4      „ 

Recovered 

No  report  since  1872 

465 

Clamp 

15      „ 

4      „ 

Recovered 

Died  in  1878 

466 

Clamp 

14      „ 

5      „ 

Recovered 

Remains  well  1872.    No  report  since 

467 

Clamp 

36      „ 

5      » 

Recovered 

Four  children  since  operation — girls 
1873-76,  boys  1879-81.  Remains  well 
in  1881 

468 

Clamp 

15      „ 

4      » 

Recovered 

Remains  well  in  1881 

469 

Clamp 

16      „ 

4      „ 

Recovered 

Died  1879  of  pneumonia 

470 

Clamp 

33      „ 

5     ,. 

Recovered 

Remains  well  in  1881 

471 

Clamp 

28      „ 

5      „ 

Recovered 

Remains  well  in  1881 

472 

Clamp     . 

19      „ 

5      .» 

Died,  4th  day 

Peritonitis 

473 

Ligature  . 

16      „ 

5      „ 

Died,  3rd  day 

Peritonitis 

474 

Ligature  . 

30      „ 

5      „ 

Died,  7th  day 

Peritonitis 

475 

Ligature  . 

>o    „ 

s     ,, 

Recovered 

Child  (girl)  born  two  months  after 
operation  at   6tli   month  of    preg- 
nancy ;  lived  21  hours  ;  girl  in  1873 
at  full  time,  still  alive.   Mother  well 
in  1881 

476 

Clamp  and  liga- 
ture 

17      „ 

7      „ 

Died,  «h  day 

Pneumonia 

477 

368 


TABLE   OF   ONE   THOUSAND   CASES 


478 
47!) 
480 


482 
483 
484 
485 
486 
487 
488 
489 
490 
491 
4112 


Mcrlical  Attendant 


408 
4H7 
498 

499 

500 

501 

502 

503 
504 
505 
506 
507 

508 
509 
510 
511 
512 
513 

514 
515 
516 
517 


Hospital 
Hospital 
Hospital 


Professor  Bardeleben 

Mr.  Lys,  Blandford 

Hospital 

Hospital 

Dr.  Day 

Mr.  Barle,  Brentwood 

Hospital 

Sir  W.  Gull,  Bart. 

Sir  W.  Gull,  Bart. 

Mr.  Moreton,  Tarvin 

Hospital 

Hospital 

Mr.  Mason  .        .    ' 

Hospital 


Dr.  Hickson,  Scarboro' 


Hospital 

Mr.  Bracey,  Birmingham 

Mr.  Whipple,  Plymouth 


Hospital      .        .       . 

Hospital       .        . 

Hospital 

Dr.  Busch,  Bamsbeck 


Hospital 

Dr.  Ormerod,  Brighton 

Hospital 

Dr.  Kesteven 

Hospital       .       .       , 

Dr.  Prior,  Bedford      . 
Mr.  "W.  Stewart   . 
Mr.  Hall,  Sheffield      . 
Dr.  Williamson    . 
Dr.  Fripp,  Clifton 
Dr.  Pagenkopff,  Moscow 

Dr.  Docker,  Boulogne 
Mr.  Mercer,  Deal 
Dr.  T.  K.  Chambers    . 
Dr.  Churchill,  Dublin 


Date 

of 

Operation. 


1872  April 

„  April 

„  April 

„  April 

„  April 

„  April 

„  April 

„  April 

„  April 

„  April 

„  May 

„  May 

„  May- 


May 
June 
June 

June 

June 
June 
June 

June 

June 

July 

July 

July 
July 
July 
July 
Aug. 

Aug. 

Aug. 
Aug. 
Aug. 

Aug. 
Aug. 

Aug. 
Oct. 
Oct. 
Oct. 


Condition 


Single 

Married 

Single 

Single 

Married 

Married 

Married 

Married 

Married 

Married 

Single 

Single 

Married 

Single 

Married 

Married 

Married 

Single 

Married 
Married 
Single 

Married 

Married 

Single 

Married 

Married 

Single 

Single 

Married 

Married 

Married 
Married 
Married 
Married 
Married 
Married 

Single 
Single 
Married 
Single 


Adhesions 


Omental       .... 
Parietal  and  omental . 
Parietal        .... 

None 

Parietal  .... 
Parietal  .... 
Parietal  and  omental . 

None 

None 

Parietal       .... 

None 

Omental  .... 
Parietal        .... 

None 

Parietal  .... 
Parietal  .... 
Burst  cyst  .... 

None    ..... 

Parietal  and  omental . 
Parietal  and  omental . 
None 

Parietal  and  omental . 

Parietal  and  omental .       . 

None 

Parietal        .... 

None 

None 

Pelvic 

Pelvic 

Omental.    Pregnant  . 

Omental  and  intestinal 
Parietal        .... 
Parietal  and  omental 
Pelvic,  omental,  and  parietal 
None    ..... 
Parietal        .... 

None 

None  ..... 
Uterine  .... 
None 


OF   COMPLETED    OVARIOTOMY 


369 


Treatment  of 
Pedicle 

Weight,  of 
Tumour 

Length 

of 
Incision 

Result 

Subsequent  History 

or 

Cause  of  Death 

NTo. 

Clamp 

20  pounds 

6  inches 

Recovered 

Remains  well  and  single  in  1881 

478 

Clamp 

24      „ 

4      „ 

Recovered 

Died,  July  1872 — obstructed  intestine 

479 

Clamp  and  liga- 
ture 

25      „ 

7     ,, 

Recovered 

No  report  since  1872 

480 

Clamp  and  liga 
ture 

12      „ 

6     „ 

Recovered 

Married     1874— three    children— boys 
1875-77  ;  girl  1879.    Well  in  1881 

481 

Clamp      . 

27      „ 

5     ,, 

Recovered 

Child  in  1877.    Remains  well  in  1881 

482 

5      » 

Recovered 

Remains  weU  in  1881 

483 

Clamp      . 

26      „ 

7     „ 

Recovered 

Remains  well  in  1881 

484 

Clamp 

8      „ 

5      » 

Recovered 

Remains  well  in  1881 

485 

Clamp 

14      „ 

4      „ 

Recovered 

Remains  well  in  1881.    Husband  dead 

486 

5      » 

Recovered 

Remains  well  in  1881 

487 

Clamp 

22      „ 

4      „ 

Recovered 

Died  1880 

488 

Clamp 

26      „ 

5      „ 

Recovered 

Remains  well  and  single  in  1881 

489 

Clamp      . 

28      „ 

4      „ 

Recovered 

Remains  well  in  1881 

490 

6      „ 

Recovered 

Remains  well  in  1881 

491 

5      „ 

Recovered 

No  report  since  1872 

492 

Clamp 

•       34      „ 

5     „ 

Recovered 

Well  in  1876.    Not  seen  since 

493 

Clamp.      Botl 
ovaries 

i       21      „ 

4      „ 

Recovered 

Died  in  1876  of  malignant  disease  of 
abdomen 

494 

Pin   and   liga 
ture.      Botl 

-       18      „ 
l 

5     „ 

Recovered 

Remains  well  in  1881 

495 

ovaries 

Ligature  . 

•       25      „ 

6     „ 

Recovered 

Remains  well  in  1881 

496 

Clamp 

•       26      „ 

5      „ 

Recovered 

Remains  well  in  1881 

497 

Clamp      . 

6      „ 

4     „ 

Recovered 

Married  -  one  child.    Remains  well  in 
1881 

498 

Clamp 

•       16      „ 

5     ,. 

Recovered 

One  child  since  operation.    Remains 
well  in  1881 

499 

Ligature  . 

•       24      „ 

5      „ 

Recovered 

Returned  to  Suffolk.    Died  a  month 
after  with  cerebral  symptoms 

500 

Clamp  and  ligj 
ture 

i-      27      „ 

5      » 

Recovered 

Married  1877— girl  born  1878.  Well  in 
1881 

501 

Clamp  and  lig£ 
ture 

"       21      „ 

6      „ 

Recovered 

Well  in  1876.    No  report  since 

502 

Clamp 

8      „ 

5      „ 

Recovered 

Well  in  July  1873.    No  report  since 

503 

Clamp 

•       13      » 

4      „ 

Recovered 

Well  in  1876.    No  report  since 

504 

Ligature  . 

7      „ 

Died,  7th  day- 

Pyasniic  fever 

505 

Clamp 

•       12      „ 

6      „ 

Died,  40  hours 

Peritonitis 

506 

Ligature . 

•       26      „ 

6      „ 

Recovered 

Had  7  months'  child  day  after  opera- 
tion.    Boys  born    Dec.    1873    and 
March  1876.    No  report  since 

507 

Clamp 

•       18      „ 

4      „ 

Recovered 

Well  in  1881 

508 

Clamp 

8      „ 

5      „ 

Recovered 

No  report 

509 

Ligature  . 

•       21      „ 

5      „ 

Recovered 

Well  in  1881 

510 

Ligature  . 

•       52      „ 

5      „ 

Died,  6th  day 

Peritonitis 

511 

Ligature  . 

6      „ 

5      » 

Recovered 

Well  in  1881 

512 

pandlig 
ture.     Lot 

i-      37      „ 
h 

5      » 

Recovered 

Well  in  1876.    No  report  since 

513 

ovaries 

Clamp 

24      „ 

6      „ 

Recovered 

Well  in  1881 

514 

Clamp     . 

21       „ 

5      „ 

Died,  5th  day 

Septicaemia 

515 

Ligature . 

18      „ 

5      „ 

Died,  42  hours 

Si'pl  ituniiiia 

516 

ip 

10      „ 

Recovered 

w.i  1  in  L881 

517 

i:  I'. 


370 


TABLE   OF   ONE   THOUSAND   CASES 


Medical  Attendant 


518 
519 
520 
521 

522 
523 

524 
525 
526 
527 
528 
529 
530 
531 
532 


534 
535 
536 
537 

538 
539 

540 
541 
542 
543 
544 
545 
546 
547 
548 
549 
550 
551 

552 
553 
554 
555 
556 
567 


559 
560 


Dr.  Thursfield,  Leamington 
Dr.  C.  E.  Roberts,  Southgate 
Dr.  Onnerod,  Brighton 
Hospital      . 


Dr.  Roche,  Chelmsford 
Dr.  Wane    . 


Mr.  Reid,  Canterbury 

Hospital 

Hospital 

Dr.  Sealy,  Barbadoes 

Hospital 

Dr.  Hawkesley    . 

Hospital 

Hospital 

Hospital 

Mr.  Edgar  Barker 

Mr.  Edgar  Barker 

Hospital 

Dr.  Churchill,  Dublin 

Dr.  Oldham 


Hospital 

Mr.  Bishop,  Tunbridge 

Mr.  Crompton,  Birmingham 

Hospital       .... 

Dr.  Watt  Black  . 

Hospital       .... 

Dr.  Sharpo,  Woolwich 

Dr.  Rutherford,  Pulborough 

Dr.  A.  Brown,  Islington     . 

Dr.  Evans,  Hertford 

Hospital 

Hospital 

Hospital 

Hospital 


Mr.  Curtis,  Alton 

Mr.  Ruddock 

Dr.  Freund,  Breslau 

Hospital 

Mr.  Hughes,  Bromley 

Dr.  Prince    . 


Dr.  Swayne,  Clifton 

Mr.  Scattcrgood,  Leeds 
Hospital 


Date 

of 

Operation 


•Vgc 


1873  Oct. 

„  Oct. 

„  Oct 

„  Oct. 

„  Nov. 

„  Nov. 

„  Nov. 

„  Nov. 

„  Jan. 

,,  Jan. 

„  Jan. 

„  Jan. 

„  Jan. 

„  Feb. 

„  Feb. 

„  Feb. 

„  Feb. 

„  Feb. 

„  Feb. 

„  Feb. 

„  Feb. 

„  Feb. 

„  March 

„  March 

„  March 

„  March 

„  March 

„  April 

„  April 

„  April 

„  April 

„  April 

„  April 

„  April 

„  May 

„  May 

„  May 

»  May 

„  May 

„  May 

■   „  June 

,,  June 

„  June 


Single 
Single 
Married 
Married 

Married 
Married 

Married 

Single 

Married 

Married 

Married 

Married 

Single 

Married 

Married 

Married 

Married 
Married 
Single 
Married 

Single 
Single 

Single 

Single 

Single 

Single 

Married 

Married 

Single 

Married 

Married 

Married 

Married 

Single 

Single 
Single 
Single 
Single 
Single 
Married 

Single 

Married 
Married 


Adhesions 


None 

None.    Burst  cyst 
Parietal  and  omental 
Omental  and  parietal 

Parietal  and  omental 
Omental  and  parietal 

Omental,  intestinal,  and  parietal 

None 

Omental 

None 

Parietal 

None 

Omental  and  parietal 

Omental 

None 


Intestinal,  omental,  and  parietal 


None  . 
Omental 
Omental 
Uterine 


None    .       .       .       . 
Omental  and  parietal 


None  . 
None  . 
Parietal 
None  . 
None  . 
None  . 
None  . 
None  . 
None  . 
Parietal 
Parietal 
Parietal 


None  . 
None  . 
None  . 
None  . 
Parietal 
None    . 


None   . 

Parietal 
None    . 


OF  COMPLETED   OVARIOTOMY 


371 


Treatment  of 
Pedicle 

Weight  of 
Tumour 

Length 

of 
Incision 

Result 

Subsequent  History 

or                                   No. 
Cause  of  Death 

Clamp 

20  pounds 

4  inches 

Recovered 

WeUinl881                                                518 

Pin  and  ligature 

36      „ 

6      „ 

Recovered 

Died  Sept.  1873.    Cancer                           519 

Ligature  . 

6      „ 

5      „ 

Died,  5th  day 

Peritonitis                                                      520 

Clamp 

21      „ 

5      „ 

Recovered 

Had  twins  in  Sept.  1873.    No  report    521 
since 

Clamp 

22      „ 

5      „ 

Died,  13  hours 

Exhaustion                                                 522 

Clamp 

41      „ 

5      „ 

Recovered 

A  child  in  1873  ;  abortion  1875  ;  child    523 
1876.    Well  in  1881 

Clamp 

10      „ 

5      „ 

Recovered 

Well  in  Dec.  1876.    No  report  since         524 

Clamp 

25      „ 

5      „ 

Died,  3rd  day- 

Obstruction  of  intestine                           525 

Clamp 

11      „ 

5      „ 

Died,  4th  day 

Peritonitis                                                   526 

Clamp 

9      „ 

5      » 

Died,  7th  day 

Peritonitis                                                   527 

Ligature  . 

19      „ 

5      » 

Died,  2nd  day 

Septicaemia                                                 528 

Clamp 

8      „ 

4      „ 

Died,  4th  day 

Uraemia  from  suppression  of  urine           529 

Clamp 

28      „ 

4      „ 

Eecovered 

Well  a  year  after.    No  report  since          530 

Ligature  . 

17      „ 

5      „ 

Recovered 

Well  Dec.  1876.    No  report  since              531 

Clamp 

13      „ 

4      „ 

Recovered 

Married  second  time   1880.     Well  in    532 
1881 

No  pedicle 

8      „ 

5      „ 

Recovered 

Well  Dec.  1876.    No  return  of  disease.    533 
Died  of  paraplegia 

Clamp 

23      „ 

4      „ 

Recovered 

Well  in  1881                                                534 

No  pedicle 

33      „ 

5      „ 

Recovered 

Died  of  pleurisy  one  year  after                 585 

Ligature  . 

4      „ 

4      „ 

Recovered 

Married  1878.    Well  in  1881                     536 

Pin  and  6cra- 
seur 

22      „ 

5      „ 

Recovered 

Well  in  lfel                                             537 

Clamp     • 

23      „ 

5      „ 

Recovered 

Well  in  1881                                                538 

Clamp     . 

11      » 

4      » 

Recovered 

Recovered    after    removal  of    other    539 
ovary  in  1874.    Died  1876,  two  years 
after  second  operation 

Clamp     . 

13      „ 

4      „ 

Recovered 

Well  in  1881                                                540 

Clamp 

19      „ 

4      „ 

Died,  8th  day 

Septicaemia                                                 541 

Clamp 

23      „ 

5      ,, 

Recovered 

Well  in  1881                                                542 

Ligature  . 

12     „ 

5     „ 

Died,  3rd  day 

Septicaemia                                                 543 

Clamp 

17      „ 

4      „ 

Recovered 

Boy  born  Feb.  1876.    Well  in  1881          544 

Clamp 

16     „ 

4     „ 

Recovered 

Died  of  cancer,  1874                                 545 

Clamp     . 

17      „ 

4      ,, 

Recovered 

Well  in  1881                                                54G 

Clamp 

16      „ 

4      „ 

Recovered 

Well  in  1881                                                547 

Clamp 

19      „ 

4      „ 

Recovered 

Well  in  1881                                                54S 

Clamp     . 

30     „ 

G     „ 

Died,  42  hours 

Exhaustion                                                 519 

Clamp     . 

50      „ 

6      „ 

Recovered 

Well  in  1881                                                550 

Clamp     . 

20     „ 

4     „ 

Recovered 

Recovered    after    removal  of   second     551 
ovary  in  1876.    Well  in  1881 

Ligature  . 

7      „ 

4     „ 

Died,  3rd  day 

Peritonitis                                                   552 

Clamp 

18      „ 

4      „ 

Died,  3rd  day 

Peritonitis                                                   553 

Clamp 

15      „ 

4      ,, 

Died,  48  hours 

Septicaemia                                                 554 

Clamp 

13      „ 

5     ,, 

Died,  12th  day 

Septicaemia                                                 555 

Clamp     . 

14     ;, 

4      „ 

Recovered 

Well  in  1881                                                   55G 

Ligature.  Lot) 
ovatie 

1       14      „ 

5      ,, 

Recovered 

Died  April  1874.    Cancer                         557 

'  lamp 

•         •        • 

4      » 

Recovered 

Married    in    1875.     Child    horn    July     658 
1S7H,  another  since.     Well  in  1KS1 

Clamp     . 

88     „ 

■>            !> 

Died,  I6tn  day 

Cardiac  embolism                                  559 

Clamp 

18     „ 

■>           „ 

Recovered 
B   B  2 

No  report                                           1 860 

372 


TABLE   OF   ONE   THOUSAND   CASES 


562 
5G3 
564 
565 
566 

567 
568 

569 

570 

•571 
572 
573 
574 
575 
576 

577 
578 
579 
580 
581 
582 
583 


585 
586 


589 
590 
591 
592 
593 

594 

595 
596 

597 
598 
599 

600 

601 


Medical  Attendant 


Dr.  Pagenkopff,  Moscow 


Hospital       .... 
Hospital       .... 
Dr.  Gonzalez,  Rio  de  Janeiro 
Hospital       .... 
Hospital       .... 


Hospital       . 

Mr.  Garraway,  Favershani 

Dr.  Thomson, 
Hospital 


Hospital       .        . 

Hospital 

Dr.  Corner  . 

Dr.  Guinness,  Oxford 

Dr.  Bell 


Dr.  P.  B.  Image,  Bury  St. 
niunds 

Hospital 

Dr.  Braxton  Hicks 

Hospital 

Dr.  Chessall,  Horley 


Dr.  Brodie 
Hospital 


Mr.  Marriott,  Swaffham 

Mr.  Biggall . 
Hospital 


Hospital 


Dr.  Hewer  . 

Hospital 

Dr.  Giles,  Oxford 

Dr.  Swayne,  Clifton 

Hospital 

Hospital 


Dr.  Gage  Brown 

Hospital 

Hospital 

Mr.  Humby. 

Dr.  Leslie,  Alton 

Hospital 


Mr.  Winter,  Brighton 
Mr.  Nunn,  Colchester 


Date 

of 

Operation 


1873  June 


June 

June 

„  June 

»  July 

„  July 

»  July 

>,  July 

„  July 

.,  July 

,.  July 

»  July 

„  Aug. 

»  Aug. 

,,  Aug. 

„  Oct. 

„  Oct. 

„  Oct. 

„  Oct. 

„  Oct. 

„  Oct. 

„  Oct. 

„  Oct. 

„  Oct. 

„  Nov. 

„  Nov. 

„  Nov. 

„  Nov, 

„  Nov. 

„  Dec. 

„  Dec. 

„  Dec. 

„  Dec. 


„  Dec. 

„  Dec. 

„  Dec. 

„  Dec. 
1874  Jan. 

„  Jan. 

„  Jan. 

„  Jan. 


Condition 


Married 

Married 

Married 

Single 

Single 

Married 

Single 
Married 

Married 
Married 

Married 

Single 

Single 

Married 

Married 

Married 

Married 

Married 

Married 

Single 

Single 

Married 

Married 

Single 

Married 
Married 

Single 

Married 

Married 

Single 

Single 

Married 

Single 

Single 

Married 

Married 

Married 

Married 

Single 

Single 
Single 


Adhesions 


Parietal 


Parietal       .... 
None 

Parietal,  intestinal,  and  pelvic 

None 

Omental      .... 


Parietal 

Parietal  and  omental 


None 
None 


None  . 

None    . 

None    . 

Parietal  and  omental 

None    . 

Parietal       .       .       . 


None    . 

Omental 

Omental      .        ■ 

Pelvic  . 

Intestinal    .        . 

Parietal 

Parietal  and  omental , 


None 


None    .... 

Omental  and  intestinal 


None 


None  . 

Omental  and  parietal . 
None    .       .       .       . 
Parietal 
Omental       . 
None    . 


Parietal 

Parietal  and  omental , 

None  . 

Parietal       .        .        . 

Parietal       . 

None    . 


Parietal 
None    . 


OF   COMPLETED   OVARIOTOMY 


373 


Treatment 

of 

Pedicle 

Weight  of 
Tumour 

Length 

of 
Incision 

Eesult 

Subsequent  History 

or 

Cause  of  Death 

No. 
561 

Clamp 

17  pounds 

6  inches 

Eecovered 

Well  in  1875.     Died  March  1881  of 
kidney  disease 

Clamp     . 

22      „ 

5     >, 

Eecovered 

No  report 

562 

Clamp 

19      „ 

5      » 

Eecovered 

Well  in  1881 

563 

Clamp     . 

125     „ 

6      „ 

Eecovered 

Returned  to  Brazil.    Well  in  1881 

564 

Clamp     . 

24      „ 

5      „ 

Died,  5th  day 

Septic  peritonitis 

565 

Clamp     . 

14     „ 

5     „ 

Eecovered 

Five  children  since  operation,  1874- 
76-78-79-81.    Well  in  1881 

566 

Clamp     . 

26     „ 

5      „ 

Eecovered 

Died  of  peritonitis,  1879 

567 

Clamp 

21      „ 

5      „ 

^Recovered 

Boy  still-born,  1875.    Girl  bom  1876. 

Well  in  1881 

568 

Ligature . 

10     „ 

5      „ 

Eecovered 

No  report 

569 

Ligature . 

34      „ 

5      » 

Eecovered 

Child  born  August  1874.     No  report 
since 

570 

Clamp     . 

27      „ 

5      „ 

Eecovered 

Well  in  1881 

571 

Ligature  , 

26      „ 

5      » 

Eecovered 

No  report 

572 

Clamp 

17     „ 

5      „ 

Eecovered 

Married  1879.    Well  in  1881 

573 

Clamp 

9      „ 

6      „ 

Died,  49  hours 

Peritonitis 

574 

5     „ 

Eecovered 

Well  in  1881 

575 

Ligature . 

40      „ 

5      >, 

Eecovered 

Well  in  1881 

576 

Clamp     . 

33      „ 

5      „ 

Eecovered 

Well  in  1881 

577 

Pin  and  ligature 

16      „ 

6      „ 

Died,  32  hours 

Exhaustion 

578 

Clamp 

13      „ 

5      „ 

Eecovered 

Well  in  1881 

579 

Clamp 

13     „ 

5      >, 

Eecovered 

Well  in  1881 

580 

Clamp 

50      „ 

5      „ 

Died,  28  hours 

Exhaustion 

581 

5      „ 

Eecovered 

Well  in  1881 

582 

Ligature  . 

18      „ 

5      „ 

Eecovered 

Well  in  1881.    Had  twelve  children 
before  operation — one  of  them  ope- 
rated on  for  same  disease  1869 

583 

Sewed    to    ab- 
dominal wall 

18      „ 

5      » 

Died,  24th  day 

Pyasmic  fever 

584 

Clamp 

12      „ 

5      „ 

Eeoovered 

Well  in  1876.    No  report  since 

585 

Clamp 

15      „ 

5      „ 

Eecovered 

Two  bovs  and  two  girls  since — born 
1875-76-77-80.    Well  in  1881 

586 

Clamp 

12      „ 

5      „ 

Eecovered 

Died     Oct.      1879— ascites,      uterine 
myoma 

587 

Clamp 

22      „ 

5      ,, 

Eecovered 

Well  in  1881 

588 

Clamp 

21      „ 

6      „ 

Eecovered 

Well  in  1876.    No  report  since 

589 

Clamp 

20      „ 

6      „ 

Died,  8th  day 

Septicaemia 

590 

Clamp 

19      „ 

4      „ 

Eecovered 

Well  in  1881 

591 

Clamp 

22      „ 

5      » 

Died,  7th  day 

Septicasmia 

592 

Clamp 

15      „ 

5      ,, 

Eecovered 

Married  1876 — two  boys,  one  girl.  Well 
in  1881 

593 

Clamp 

4      „ 

Eecovered 

Well  in  1881 

594 

Clamp 

21      „ 

s     „ 

Eecovered 

Well  in  1876.    No  report  since 

595 

Clump 

32      „ 

5      „ 

Eecovered 

Well  in  1881 

596 

Ligature  ■ 

24      „ 

G      ,, 

Died,  21  hours 

Exhaustion 

597 

Clamp     . 

21      „ 

5      „ 

Died,  53  hours 

Exhaustion 

598 

Clamp 

35      „ 

5      „ 

Eecovered 

Well  in  1876— (lied  in  1879  of  disease 
of  liver 

599 

Clamp 

46      „ 

6      ., 

Recovered 

Well  in  1881 

600 

damp 

12      „ 

4      „ 

Recovered 

Well  in  1876- -uterine  hseniatocele  in 
L881-    still  alive 

601 

374 


TABLE   OF   ONE   THOUSAND   CASES 


No. 


Medical  Attendant 


602 
603 

604 
605 

606 
607 
COS 

609 
610 
611 
612 
613 
614 
615 
616 
617 

618 
619 

620 
621 
622 
623 
624 
625 
626 
627 
628 
629 
630 
631 
632 
633 

634 
635 


637 
638 
639 
640 
641 
642 
643 


Hospital 

Hospital 

Dr.  Lane,  San  Francisco    . 

Dr.     Highmore,    Bradford-on- 
Avon 

Hospital 

Hospital 

Professor      Dohrn, 


Prussia 
Dr.  Clifton,  Leicester  . 
Hospital 

Dr.  Wyman,  Putney  . 
Hospital 

Mr.  Pilcher,  Boston    . 
Dr.  Neil  Arnott  . 
Hospital 
Hospital 
Dr.  Borland,  Boston,  U.S. 


Marburg, 


Hospital 
Hospital 


Hospital 

Mr.  Barrett,  Pewsey,  Wilts 

Dr.  Monro,  Barnard  Castle 

Hospital 

Hospital 

Dr.  Thomson,  Torquay 

Mr.  AVoodward,  Tooting 

Mr.  Harper,  Holbeach 

Hospital 

Mr.  Nicholson,  Stratford 

Hospital 

Dr.  Bright,  Forest  Hill 

Hospital 

Mr.  Everett,  Worcester 

Dr.  Britton,  Clifton    . 
Dr.  Veit,  Bonn    . 

Hospital 

Hospital 

Hospital 

Mr.  Baker,  Birmingham 

Dr.  Veit,  Bonn    . 

Hospital 

Dr.  Wykl     . 

Dr.  Swayne,  Clifton    . 


Date 

of 

Operation 


Age 


Condition 


1874  Jan. 

„  Jan. 

„  Jan. 

„  Jan. 

„  Feb. 

„  Feb. 

„  Feb. 

„  Feb. 

„  Feb. 

„  Feb. 

„  Feb. 

„  Feb. 

„  March 

„  March 

„  March 

„  March 

„  March 

„  April 

„  April 

„  April 

„  April 

„  April 

„  April 

„  April 

„  May 

„  May 

„  May 

„  May 

„  May 

„  May 

„  May 

„  May 

„  May 

„  May 

„  May 


June 

34 

Married 

June 

34 

Married 

June 

45 

Married 

June 

3U 

Single 

June 

20 

Single 

June 

54 

Married 

June 

■IS 

Married 

Married 
Single 
Single 
Single 

Married 
Married 
Married 

Married 

Single 

Single 

Single 

Married 

Married 

Married 

Married 

Single 

Married 
Married 

Single 
Married 
Married 
Widow 
■  Single 
Married 
Married 
Married 
Married 
Single 
Married 
Married 
Married 
Married 

Married 
Married 


Adhesions 


Omental 

None 

None 

None 

Omental 

None 

None 

Parietal 

Omental 

Intestinal 

None 

None 

None 

Omental  and  parietal . 
Omental,  parietal,  and  intestinal 
None 

Parietal 

Omental 

Omental  and  intestinal 

Omental 

Parietal 

None 

Parietal 

None 

Omental  and  parietal 

Parietal,  omental,  and  vesical    . 

Omental  and  parietal . 

None 

Intestinal  and  uterine 

None 

Parietal 

None 

Omental 

None 

None 

Parietal 

None 

Pelvic  and  omental    . 

None 

None 

None 

Parietal  and  pelvic     . 


OF   COMPLETED   OVARIOTOMY 


375 


Treatment 

of 

Pedicle 


Clamp  . 
Ligature  . 
Ligature  . 
Clamp      . 

Clamp 
Clamp 
Clamp 

Clamp 

Clamp 

Clamp 

Clamp 

Clamp 

Clamp      . 

Ligature  . 

Clamp 

Clamp 

Clamp 
Clamp 

Clamp      . 

Clamp 

Clamp      . 

Clamp 

Clamp 

Clamp 

Clamp 

Clamp     . 

Clamp 

Clamp 

Clamp 

Clamp 

Clamp 

Clamp  and  liga- 
ture. Both 
ovaries 

Clamp  •  . 

Clamp 

Clampandliga- 
tnre.  Both 
ovaries 

Clamp 
Clamp 
Clamp 
Clamp 
Clamp 
Clamp 
Clamp  and  liga 
Botl 


Weight  of 

Length 

of 
Incision 

Tumour 

24  pounds 

5  inches 

16      „ 

4      » 

2      „ 

4      » 

17      „ 

5      » 

24      „ 

6      „ 

17      „ 

5      „ 

16      „ 

4      „ 

15      „ 

5      „ 

26      „ 

5      » 

20      „ 

4      „ 

12      „ 

5      » 

16      „ 

5      „ 

20      „ 

5      .. 

14      „ 

. 

21      „ 

8      „ 

4      „ 

28      „ 

5      „ 

26      „ 

5      ., 

16      „ 

5      „ 

. 

5      „ 

17      „ 

5      „ 

12      „ 

4      „ 

8      „ 

4      „ 

10      „ 

5      » 

47      „ 

6      „ 

15      „ 

6      „ 

30      „ 

5        :, 

8      „ 

4      „ 

24      „ 

5      „ 

12      „ 

5      » 

27      „ 

5      „ 

10      „ 

6      „ 

32      „ 

6      » 

12      „ 

5      » 

27      „ 

5      „ 

28      „ 

5      „ 

21      „ 

5      „ 

18      „ 

5      „ 

0      » 

5      » 

12      „ 

4      „ 

15      „ 

5       „ 

IGi     „ 

5       „ 

Result 


Recovered 
Recovered 
Recovered 
Recovered 

Recovered 
Recovered 
Recovered 

Recovered 
Died,  4th  day 
Recovered 
Died,  17th  day 
Recovered 
Died,  2nd  day 
Recovered 
Recovered 
Recovered 

Recovered 
Recovered 

Recovered 

Recovered 

Died,  9th  day 

Recovered 

Recovered 

Recovered 

Died,  3rd  day 

Recovered 

Died,  5th  day 

Died,  4th  day 

Died,  5th  day 

Recovered 

Recovered 

Recovered 

Died,  22  hours 
Recovered 

Recovered 

Died,  3rd  day 
Recovered 
Died,  5th  day 
Died,  11th  day 
Recovered 
Recovered 
Died,  50  hours 


Subsequent  History 

or 

Cause  of  Death 


Boy  bom  March  1877— well  in  1881 
Married  Sept.  1880.     "Well  in  1881 
"Well  in  1881 
Died  A.ug.  1875— cancer  of  pedicle 

No  report 
No  report 
Well  in  1881 

Well  in  1881 

Congestion  of  lungs 

Died  of  phthisis 

Clot  in  cerebral  sinuses 

■Well  in  1881 

Pulmonary  congestion 

Well  in  1881 

Well  in  1876.    No  report  since 

Married  1877— two  children  1878-80. 
Well  in  1881 

Well  in  1881 

Died  after  another  ovariotomy  in  hos- 
pital, Boston,  U.S.,  in  1878 

Boy  bom  July  1876.    No  report  since 

Well  in  1S81 

Purulent  peritonitis 

No  report 

Well  in  1881 

WeU  in  1881 

Septic  peritonitis 

Well  in  1881 

Septic  peritonitis 

Septicaemia 

Septic  peritonitis 

Died  1875.    Heart  disease 

No  report 

Well  in  1881 

Septicaemia 

Well  in  1876  ;  abortion  in  1879.    Well 
in  1881 

Well  in  1 876.    No  report  since 

Haemorrhage  and  septicaemia 

Well  in  1881 

Peritonitis 

Clot  in  pulmonary  artery 

Died,  1880,  of  phthisis 

Well  in  1881 

SeptiesBmia 


376 


TABLE   OF   ONE   THOUSAND   CASES 


Medical  Attendant 


644  Hospital 
Hospital 


645 
646 

647 
648 

649 
650 
651 
652 


654 
655 
656 
657 


66U 

661 

662 
663 
664 

665 
666 
667 
668 

669 
670 
671 
672 
673 
674 
675 
676 
677 
678 
679 
680 
681 
682 


Hospital 

Dr.  Winckel,  Dresden 
Dr.  Gage  Brown  . 


Mr.  Hewer  . 

Dr.  Magrath,  Teignmouth. 

Dr.  Roberts,  Port  Madoc 

Hospital 


Mr.  Hewlett,  Harrow . 

Hospital 

Mr.  Burton,  Blackheatk 

Dr.  Horsford,  Stratford 

Hospital 

Mr.  Walker,  "Wakefield 

Dr.  Owen  Rees    ,       . 


Hospital       .        .        . 
Mrs.  Garrett- Anderson 


Hospital 

Mr.  Coates,  Salisbury 

Dr.  Pauly,  Ebersvalde 

Dr.  Gordon,  Belfast    , 
Mr.  Clover  . 
Dr.  Wood,  New  York , 
Mr.  Taylor,  Guildford 

Hospital 

Sir  W.  Gull,  Bart.       . 

Hospital 

Hospital 

Hospital 

Mr.  Payne,  Cambridge 

Dr.  Wharton  Hood     . 

Hospital 

Mr.  Forster,  Daventry 

Hospital 

Hospital 

Hospital 

Dr.  Fawcett,  Cambridge 

Hospital 

Dr.  Lanchester,  Croydon 

Dr.  Prcll,  Hamburg    . 


Date 

of 

Operation 


1874  June 
„    June 

,,    July 

„    July 
„    July 

„  July 

„  July 

„  July 

„  July 

„    July 

„  Aug. 

„  Aug. 

„  Oct. 

„  Oct. 

„  Oct. 

„  Oct. 

„    Nov. 

„    Nov. 

„  Nov. 
„  Nov. 
„    Nov. 

„  Nov. 

„  Dec. 

„  Dec. 

„  Dec. 

„  Dec. 

„  Dec. 

„  Dec. 

1875  Jan. 

„  Jan. 

„  Jan. 

„  Jan. 

„  Jan. 

„  Jan. 

„  Jan. 

„  Jan. 

„  Jan. 

„  Feb. 

„  Feb. 

„  Feb. 

„  Feb. 


A.ge 

Condition 

58 

Married 

58 

Married 

26 

Married 

24 

Married 

39 

Married 

54 

Single 

16 

Single 

62 

Married 

37 

Married 

Single 

Single 

Married 

Married 

Single 

Widow 

Married 

Married 

Single 

Single 

Married 

Married 

Married 
Single 
Married 
Single 

Single 

Single 

Single 

Widow 

Single 

Single 

Married 

Married 

Single 

Single 

Married 

Married 

Single 

Single 

Married 

Married 


Omental 

Omental  and  parietal . 


Omental 


Parietal  and  omental 
Omental 


Parietal 

Parietal,  omental,  and  intestinal 

None 

Intestinal,  vesical,  and  uterine  . 


None 


None    ...... 

None 

Parietal  and  omental 

None 

None 

Parietal  and  omental . 

Parietal,  omental,  vesical,  and 
uterine 

None 


Parietal  and  omental 
None    . 
None    . 


Parietal 

Parietal       .        .        . 

Uterine 

Omental  and  intestinal 


Omental      .... 

None 

Parietal  and  uterine   . 
Omental      .... 

None 

Parietal  .... 
Parietal  and  mesenteric  . 
Parietal  .... 
Omental 

Parietal,  intestinal,  and  pelvic 
Parietal  .... 
Omental  .... 
Omental  .... 
Parietal  .... 
Parietal  and  omental . 
None    .       .       ... 


OF   COMPLETED    OVARIOTOMY 


37^ 


Treatment 

of 

Pedicle 

Weight  of 
Tumour 

Length 

o£ 
Incision 

Eesult 

Subsequent  History 

or 

Cause  of  Death 

No. 
644 

Ligature  . 

27  pounds 

6  inches 

Died,  32  hours 

SepticEemia 

Ligature.  Both 
ovaries 

18      „ 

5      „ 

Died,  5th  day 

Septic  peritonitis 

645 

Clamp 

164    ,, 

5      » 

Recovered 

One  child  born  within  a  twelvemonth, 
three  others  since,  1877-78-79.  Well 
in  1881 

646 

Clamp 

4      „ 

Recovered 

Child  born  in  1880.    Well  in  1881 

647 

Clamp 

24      „ 

5      „ 

Recovered 

Child  born  December  1875.    Well  in 
1881 

648 

Clamp 

21      „ 

Recovered 

WeU  in  1881 

649 

Clamp 

10      „ 

6      „ 

Recovered 

Well  in  1881. 

650 

Clamp 

13      „ 

4      „ 

Recovered 

No  report 

651 

Clamp  and  liga- 
ture 

33      „ 

6      „ 

Died,  26  hours 

Peritonitis 

652 

Ligature.  Both 
ovaries 

20      „ 

5      „ 

Recovered 

Married    1876.      Well  in  1881.     Not 
menstruated  since  operation 

653 

Clamp 

20      „ 

5      » 

Recovered 

Married  1879.    Well  in  1881 

654 

Clamp 

38J    „ 

5      » 

Died,  50  hours 

Septicaemia 

655 

Ligature  . 

14      „ 

5      „ 

Recovered 

Died  in  1875  of  cancer 

656 

Clamp 

17i    „ 

5      „ 

Recovered 

No  report 

657 

Clamp     . 

11      „ 

5      « 

Recovered 

Well  in  1881 

658 

Ligatures.  Both 
ovaries 

55      „ 

8      „ 

Recovered 

Died  Feb.  1875 

659 

Clamp     . 

16      „ 

5      „ 

Recovered 

Girl    1876  —  miscarriage    1877— boys 
1878-80.    Well  in  1881 

660 

Ligatures.  Both 
ovaries 

10      „ 

5      „ 

Recovered 

Well  in  1881 

661 

Clamp 

15      „ 

5      ,, 

Recovered 

Well  in  1881 

662 

Clamp 

13      „ 

Recovered 

Well  in  1876.    No  report  since 

663 

Clamp  and  liga- 
ture.     Both 
ovaries 

12      „ 

5      „ 

Recovered 

Well  in  1881 

664 

Clamp 

9      » 

5      „ 

Recovered 

Child  born  Oct.  1876.  No  report  since 

665 

Clamp 

15      „ 

5      „ 

Recovered 

Well  in  1881 

666 

Ligature  . 

10      „ 

5      „ 

Died,  13th  day 

Obstruction  of  intestine 

667 

Ligatures.  Both 
ovaries 

15       „ 

6      „ 

Died,  30  hours 

Peritonitis 

668 

Clamp 

17      „ 

6      „ 

Died,  4th  day 

Septicaemia 

669 

Clamp 

18      „ 

4      „ 

Recovered 

Well  and  married  in  1881 

670 

Clamp 

41      „ 

5      „ 

Recovered 

Well  in  1876.    No  report  since 

671 

Clamp 

9      » 

5      „ 

Recovered 

WeU  in  1876.    No  report  since 

672 

Clamp 

2      „ 

3      „ 

Recovered 

Died  of  broncho-pneumonia  May  1875 

673 

Clamp 

20      „ 

5      „ 

Recovered 

Married  1880— boy  1881.    Well 

674 

Clamp 

13      „ 

5      „ 

Recovered 

Well  in  1881 

675 

i 

4       „ 

5       „ 

Recovered 

Well  in  1881 

676 

Ligature . 

14       „ 

s     » 

Recovered 

Well  in  1881 

677 

Clamp 

4       „ 

4      „ 

Died,  28  hours 

Peritonitis 

678 

Clamp 

13      „ 

5       » 

Died,  8th  day 

Septicaemia 

670 

i 

30      „ 

5      » 

Recovered 

No  report 

680 

Clamp 

11       » 

5       „ 

Recovered 

Died  1877 

681 

Clamp 

'I       „ 

5      „ 

Recovered 

Well  in  1881 

682 

Clamp 

4      „ 

1  ;,(■(•.  ivitciI 

Boy  1878,  girl  1880.    Well  in  1881 

683 

Clamp 

I"      ,. 

4      „ 

Recovered 

Well  in  L881 

684 

378 


TABLE   OF   ONE   THOUSAND   CASES 


687 

688 
689 
690 
691 


693 
694 
695 
696 

697 

698 
699 
700 

701 

702 
703 

70! 


706 
707 

708 
709 
710 
711 
712 

713 
714 
715 
716 

717 
718 
719 
720 
721 

722 

723 

724 


Medical  Attendant 


Hospital 


Hospital 

Dr.  "Weir,  Malvern 


Hospital 

Dr.  Griffith,  Camberwell 

Hospital 

Hospital 


Dr.  Pagenkopff,  Moscow    . 

Dr.  Hill,  Lyniington  . 
Dr.  Rice       .... 
Dr.  Manifold,  Liverpool      . 
Mr.  Robinson,  Bedford 

Mr.  Shepherd,  "Worcester   . 
Dr.  G-oldschrnidt,  Hamburgh 
Dr.  Newman,  Stamford 
Hospital      .... 
Hospital      .... 


Dr.  Holman,  Reigate 
Dr.  Kugler,  Stettin 
Mr.  Dodd     .        , 


Mr.  Barker 


Mr.  Orton,  Narborough 
Hospital 


Hospital 

Mr.  Blackstone    . 
Dr.  Symes  Thompson 
Dr.  Griffith,  Swansea 
Mr.  Copestake,  Derby 


Hospital 

Hospital 

Dr.  Rooke,  Cheltenham 

Mr.  Turner,  Hereford 


Hospital      .... 
Dr.  Johnson,  Tunbridge  Wells 
Hospital       .... 
Dr.  Dill,  Brighton      . 
Hospital      . 


Hospital 
Hospital 
Mr.  F.  Hutchinson 


Date 

of 

Operation 


1875  Feb. 

„  Feb. 

„  Feb. 

„  Feb. 

„  March 

„  March 

„  March 

„  March 

„  March 

„  April 

„  April 

„  April 

„  April 

„  April 

„  April 

„  April 

„  April 


May 
May 
May 

May 

May 
May 

June 
June 
June 
June 
June 

June 
June 
July 
July 

July 
July 
July 
July 
Oct. 

Oct. 

Oct. 

Oct. 


A-ge 


Condition 


Single 

Single 
Married 

Married 
Single 
Single 
Married 

Married 

Single 
Married 
Married 
Married 

Single 

Married 

Married 

Married 

Single 

Single 

Married 

Single 

Married 

Married 
Single 

Married 

Widow 

Single 

Single 

Single 

Widow 
Married 
Married 
Married 

Married 

Single 

Widow 

Single 

Married 

Married 

Single 

Single 


None 

None 

No  trae  pedicle   .... 

Parietal  and  omental .       . 

None 

Pelvic 

Parietal  and  omental . 

Intestinal,  uterine,  &c. 

None 

Parietal  and  omental . 
Parietal  and  omental . 
None 

None 

None 

Omental 

Omental 

Parietal,  omental,  and  between 
the  two  tumours 

Parietal 

None 

None 

Parietal  and  omental . 

None 

None 

Omental  and  intestinal 

Omental 

None 

None 

Parietal,  omental,  and  intestinal 

Intestinal 

Omental 

Omental 

Omental  and  intestinal 

Omental 

Omental  and  intestinal 

Omental 

None 

Parietal  and  omental 

Parietal  and  on.ental 

Parietal,  omental,  uterine,  and 
vesical 

None 


OF    COMPLETED   OVAKIOTOMY 


379 


Treatment 

of 

Pedicle 

Weight  of 
Tumour 

Length 

of 
Incision 

Result 

Subsequent  History 

or 

Cause  of  Death 

No. 

685 
686 

Clamp.      Both 
ovaries 

Clamp 

22  pounds 
14      „ 

5  inches 
5      „ 

Recovered 
Recovered 

Married  1879.    Well  in  1881 
Well  in  1881 

Clamp 

15      „ 

5      ,, 

Recovered 

Died  after  removal  of  a  tumour  of  the 
pedicle  1880 

687 

Clamp 

9      ,, 

5      „ 

Recovered 

Two  girls  1876-78.    Well  in  1881 

688 

Clamp 

20      „ 

5      „ 

Died,  3rd  day 

Peritonitis 

689 

Clamp 

22      „ 

5      „ 

Recovered 

Well  Dec.  1876.    No  report  since 

690 

Ligature  . 

55      „ 

6      „ 

Recovered 

Child  born  July  1876.  Died  April  1879 
of  cancer 

691 

Clamp  and  liga- 
ture 

33      „ 

6      „ 

Died 

Obstruction  of  intestine  ■ 

692 

Clamp 

14      „ 

5       ',, 

Recovered 

Well  iu  1881 

693 

Clamp 

22      „ 

5      » 

Recovered 

Well  in  1876.    No  report  since 

694 

Clamp 

13      „ 

5      „ 

Recovered 

Well  in  1881 

695 

Clamp 

5      „ 

Recovered 

Still-bom  boy  April  1876.    Died  Dec. 
1877  of  cancer  of  uterus 

696 

Clamp 

11      » 

4       n 

Recovered 

Well  in  1881 

697 

Clamp 

10      „ 

4      „ 

Recovered 

Well  in  1881 

698 

Ligature . 

15      „ 

6      „ 

Recovered 

Well  Dec.  1876.    Died  1881 

699 

Clamp 

22      „ 

6      „ 

Recovered 

Well  in  18S1 

700 

Ligatures (both 
pedicles) 

20      „ 

7      „ 

Died,  26  hours 

Exhaustion 

701 

Clamp 

14      „ 

4      „ 

Died,  3rd  day- 

Septicaemia 

702 

Clamp 

77      „ 

5      » 

Recovered 

Well  in  1881 

703 

Clamp      .        . 

9      „ 

4      „ 

Recovered 

Harried  Oct.  1875— three  girls  1877- 
78-79.    Well  in  1881 

704 

5      „ 

Recovered 

Well  in  1876.     Second  operation  in 
1880.    Well  in  1881 

705 

Clamp 

10      „ 

5      „ 

Recovered 

Well  in  1876.    No  report  since 

706 

Clamp 

19      » 

6      „ 

Recovered 

Married  April  1881— pregnant  in  Sept. 
Well 

707 

Clamp 

42 

7      „ 

Died,  10th  day 

Peritonitis 

708 

Clamp 

26      „ 

5      „ 

Recovered 

Well  in  1881 

709 

Ligature  . 

4      „ 

6      „ 

Died,  9th  day 

Peritonitis 

710 

5      „ 

Recovered 

Well  in  1876.    No  report  since 

711 

Ligature.  Both 
ovaries. 

13      „ 

5      „ 

Recovered 

Died  Oct.  1876.     Cancer 

712 

Clamp     .        , 

20      „ 

5      „ 

Recovered 

Well  in  1881 

713 

Ligature  . 

19      „ 

5      „ 

Died,  6th  day 

Septicaemia 

714 

Clamp 

21      „ 

5       „ 

Recovered 

Well  in  1881 

715 

Clamp 

11      „ 

5      „ 

Recovered 

Boy  in  1877,  miscarriage  1879.    AVell 
in  1881 

716 

Clamp 

22      „ 

5      ., 

Recovered 

Well  in  1881 

717 

Clamp 

10      „ 

5      „ 

Recovered 

Well  in  1881 

718 

Clamp 

2G      „ 

G      „ 

Recovered 

Well  in  1881 

719 

Clamp 

5      „ 

7      „ 

Died,  6th  day 

Septicasmia 

720 

Clamp 

12      „ 

5      ,, 

Recovered 

Three  girls  since  operation,  born  1S76 
-78-80.     Well  in  1881 

721 

Clamp 

33      „ 

•5      „ 

Recovered 

Well  and  pregnant  1870.    No  report 
since 

722 

. 

28      „ 

8      „ 

Died,  3rd  Way 

Septicaemia 

72.3 

1  la  mp 

12      „ 

1 

Recovered 

Well  in  lss  i 

721 

380 


TABLE   OF   ONE   THOUSAND   CASES 


No. 


725 

726 

727 
728 
729 

730 

731 
732 
733 
734 
735 
736 
737 
738 
739 
740 
741 
742 
74:; 
744 
745 
746 
747 
7-1 S 

749 
750 
751 
752 
753 
754 
755 

756 
757 
758 

759 
760 
761 
762 
763 

764 
765 
766 

767 

768 


Medical  Attendant 


Hospital 
Hospital 


Dr.  Edis 
Hospital 
Dr.  Percy  Boulton 

Mr.  J.  W.  Allen  . 


Hospital 

Hospital 

Sir  H.  Thompson 

Mr.  Edgar  Barker 

Mr.  Foster,  Huntingdon 

Dr.  Lowe,  Lynn 

Dr.  Scott,  Huddersfield 

Mr.  Morant  Baker   _  . 

Hospital 

Dr.  Smart,  Hackney  . 

Mr.  Manifold,  Liverpool 

Hospital 

Mr.  Proctor,  Tunstall 

Hospital 

Dr.  Norton  . 

Dr.  Bright,  Forest  Hill 

Dr.  Herzfeld,  Hamburg 

Hospital 


Dr.  Neftel,  New  York 

Hospital 

Hospital 

Dr.  Kidd,  Dublin 

Hospital 

Dr.  Frasch,  Naugard  . 

Dr.  De  Boubaix,  Brussels 


Dr.  Day 
Hospital 
Dr.  Kidd 


Mr.  Whittington,  Tuxford 

Hospital 

Hospital 

Mr.  Harrison,  Chester 

Hospital 


Hospital 
Hospital 
Dr.  M'Clintock,  Dublin 

Hospital 

Dr.  Thomson,  Armagh 


Date 

of 

Operation 


1875  Oct. 
„  Nov. 

„  Nov. 

„  Nov. 

„  Nov. 

„  Nov. 

„  Nov. 

„  Nov. 

„  Nov. 

„  Nov. 

„  Nov. 

„  Dec. 

„  Dec. 

1876  Jan. 
„  Jan. 
„  Jan. 
„  Jan. 
„  Jan. 
„  Jan. 
„  Feb. 
„  Feb. 
„  Feb. 
„  Feb. 
„  Feb. 

„  Feb. 

„  Feb. 

„  March 

„  March 

„  March 

„  April 

„  April 

„  April 

„  April 

„  April 

„  April 

„  April 

„  April 

„  April 

„  May 

„  May 

„  May 

„  May 

„  May 

.,  May 


Age 


Condition 


Married 
Single 

Married 

"Widow 

Single 

Widow 

Single 

Single 

Single 

Widow 

Single 

Single  ■ 

Single 

Single 

Single 

Married 

Married 

Married 

Married 

Single 

Married 

Single 

Single 

Married 

Single 

Single 

Married 

Married 

Single 

Single 

Married 

Married 
Married 
Single 

Married 

Single 

Married 

Married 

Single 

Single 

Married 

Single 

Married 

Single 


Adhesions 


Omental 
None    . 


Parietal  and  omental 

Parietal  and  omental 

Parietal,    omental,     intestinal, 
and  uterine. 

None 

Parietal  and  omental 

None 

None 

Intestinal 

Omental 

None 

None 

None 

Omental 

Parietal,  omental,  and  intestinal 

Parietal 

None 

None 

Parietal 

Parietal  and  omental 

Intestinal 

Omental 

Omental  and  pelvic    . 

None    ...... 

None 

Pelvic 

Parietal  and  omental.  Pregnancy 

Omental 

Parietal  and  omental 

Parietal,  omental,  and  vesical   . 

None 

Parietal  and  omental 

Omental 

Parietal 

Omental 

Parietal 

Omental  and  mesenteric    . 
None 

None 

None 

None    ... 

Parietal  and  omental 
Parietal       ... 


OF   COMPLETED   OVAEIOTOMY 


381 


Treatment 

of 

Pedicle 

"Weight  of 
Tumour 

Length 

of 
Incision 

Result 

Subsequent  History 

or 

Cause  of  Death 

No. 

725 

Clamp 

12  pounds 

5  inches 

Recovered 

Well  in  1881 

Clamp  and  li- 
gature. Both 

30      „ 

5      „ 

Died,  2nd  day- 

Septicemia 

726 

ovaries 

Clamp     . 

20      „ 

5      ,, 

Recovered 

Well  in  1881 

727 

Ligature  . 

15      „ 

5      „ 

Recovered 

Well  June  1876.    No  report  since 

728 

Clamp      .        . 

25      „ 

5      „ 

Died,  8th  day 

Exhaustion  (?) 

729 

Clamp 

13      „ 

5      „ 

Recovered 

Well  hi  1876.    Died  Oct.  1879  of  me- 
ningitis 

730 

Clamp 

29      „ 

5      „ 

Died,  45  hours 

Septic  peritonitis 

731 

Clamp 

41      „ 

5      „ 

Recovered 

Well  Nov.  1876.    No  report  since 

732 

Clamp 

11      „ 

4      „ 

Recovered 

Married  1880.    Well  in  1881 

733 

Clamp      .        . 

29      „ 

5      „ 

Recovered 

Well  in  1881 

734 

Clamp 

10      „ 

4      „ 

Recovered 

Well  in  1881 

735 

Clamp 

6      „ 

4      „ 

Recovered 

Well  Nov.  1876.    Died  of  cancer  1880 

736 

Clamp     .        . 

14      » 

4      „ 

Died,  19th  day 

Intestinal  obstruction 

737 

Clamp     . 

15      „ 

5      „ 

Died,  2nd  day 

Septicasmia 

738 

Clamp     .        . 

10      „ 

5      „ 

Recovered 

Well  in  1881 

739 

Clamp     . 

17      „ 

6      „ 

Recovered 

Well  in  1881 

740 

Clamp     . 

11      „ 

5      „ 

Recovered 

Well  in  1881 

741 

Clamp 

9      „ 

4      „ 

Recovered 

Well  in  1881 

742 

Clamp     .        . 

47      „ 

5      „ 

Recovered 

Well  Nov.  1876.    No  report  since 

743 

Clamp 

13      „ 

5      » 

Recovered 

WeU  Nov.  1876.    Died  1879 

744 

Clamp 

15      „ 

5      „ 

Recovered 

Well  in  1881 

745 

Clamp 

9      » 

5      „ 

Recovered 

WeU  in  1881 

746 

Ligature  . 

15      „ 

5      „ 

Died,  6th  day 

Cancer 

747 

Clamp 

11      » 

5      » 

Recovered 

Well  and  pregnant  Dec.  1876.     No 
report  since 

748 

Clamp     . 

9      „ 

4      „ 

Recovered 

Well  in  1881 

749 

Clamp 

16      „ 

5      „ 

Recovered 

Well  in  1881 

750 

Clamp 

8      „ 

5      » 

Recovered 

Well  Dec.  1876.    No  report  since 

751 

Ligature  . 

5      „ 

Died,  7th  day 

Exhaustion  after  delivery 

752 

Clamp 

11      » 

5      „ 

Recovered 

Well  in  1881 

753 

Clamp 

31      „ 

6      „ 

Died,  6th  day 

Peritonitis 

754 

Ligatures.  Both 

20      „ 

5      „ 

Died,  8  weeks 

Pelvic  abscess 

755 

ovaries 

Clamp 

10      „ 

5       „ 

Recovered 

Well,  Dec.  1876.    No  report  since 

756 

Clamp     . 

26      „ 

6      „ 

Recovered 

Well  Nov.  1876.    No  report  since 

757 

Ligatures.  Both 

15      „ 

5      „ 

Recovered 

Well  in  1881 

758 

ovaries 

5      ., 

Recovered 

Well  in  1881. 

759 

Clamp 

9      » 

5      „ 

Died,  7th  day 

Septic  peritonitis 

760 

Clamp 

19      „ 

5      » 

Recovered 

Well  in  1881 

761 

Ligature  . 

25      „ 

•5      » 

Recovered 

Well  Dec.  1876.    Died  of  cancer  1877 

762 

Clamp  and  liga- 
ture.     Both 

19      ,. 

5      „ 

Recovered 

Well  in  1881 

763 

ovaries 

Clamp 

9      » 

6      „ 

Recovered 

Died  Oct.  1876— cancer 

761 

Clamp 

18      „ 

5      » 

Recovered 

No  report 

705 

Clamp 

23      „ 

5      » 

Recovered 

Married    May  1877— girl    born    1880. 
Well  in  1881 

766 

Clamp 

23      „ 

5      M 

Recovered 

Well  in  1881 

767 

Clamp 

17      ., 

B      ., 

Recovered 

Well  in  1881 

768 

382 


TABLE   OF    ONE   THOUSAND    CASES 


769 
770 
771 
772 
773 
774 

775 
776 

777 

778 
779 

780 
781 
782 
783 
784 
785 
786 
787 


789 
790 

791 

792 
793 

794 
795 
796 


799 
800 

801 
802 

803 

804 

805 

806 
807 


Medical  Attendant 


Hospital  .... 
Hospital  .... 
Hospital  .... 
Hospital  .... 
Mr.  Nason,  Stratford-on-Avon 
Dr.  Priestley 


Hospital 
Hospital 
Hospital 


Dr.  Iliewicz,  Jerusalem 
Hospital 


Mr.  Lowe,  Burton-on-Trent 

Hospital 

Mr.  Rigden,  Lewes 

Sir.  H.  Thompson 

Mr.  Archer  . 

Dr.  Coates,  Bath  . 

Dr.  Hawkesley    . 

Hospital 

Mr.  Ceely,  Aylesbury 

Dr.  Hodder,  Toronto 
Mr.  Crosby,  Salford 

Sir  William  Gull,  Bart. 

Dr.  Schonfeldt,  Labes 
Mr.  Hodgson,  Brighton 

Dr.  Clarke,  Huddersfield 

Hospital 

Dr.  Cardozo,  Richmond 


Hospital 
Dr.  Roberts 


Hospital 
Hospital 


Dr.  Daley,  Hull 
Mr.  Mould    . 
Hospital 


Dr.  Giles,  Oxford 

Mr.  Appleby,  Newark 

Mr.  Tarleton,  Stockton 
Hospital 


Date 

of 

Operation 


1876  May 
„  June 
„  June 
„  June 
„  June 
,,    June 


June 
June 

July 

July 
July 

July 
July 
July 
July 
July 
July 
July 
July 
July 

Aug 

Auj 

Aug, 

Aug, 
Sept 

Sept, 
Oct. 
Oct. 

Oct. 
Oct. 

Oct. 
Oct. 

Oct. 
Oct. 
Oct. 

Oct. 

Oct. 

Oct. 
Nov. 


A.ge 


Condition 


Single 

Single 

Married 

Single 

Single 

Married 

Single 
Single 
Single 

Single 
Single 

Married 

Single 

Single 

Single 

Single 

Single 

Single 

Single 

Single 

Married 
Married 

Married 

Single 
Married 

Married 

Single 

Single 

Single 
Married 

Single 
Married 

Single 
Widow 
Single 

Single 

Widow 

Married 
Single 


Adhesions 


None 

Parietal  and  intestinal 

Omental 

Parietal 

None 

None 

None 

None 

None 

None 

Parietal,  omental,  uterine,  and 
the  two  ovaries  bound  to- 
gether. 

Parietal  and  omental 

None 

Parietal  omental,  and  vesical   . 

Parietal  and  intestinal 

Parietal,  hepatic,  and  intestinal 

None 

None 

None 

None 

Intestinal,  pelvic,  and  uterine   . 
Omental 

None 

None 

Parietal  and  omental 

Omental 

Parietal 

None 

Intestinal,  vesical,  and  uterine  . 
None.    Pregnant 

Parietal 

Intestinal  and  pelvic . 

None 

Omental       . 
Parietal  and  omental . 

None 

Omental       .... 

Parietal       .... 
None 


OF   COMPLETED   OVARIOTOMY 


383 


Treatment 

of 

Pedicle 

Weight  of 
Tumour 

Length 

of 
Incision 

Result 

Subsequent  History 

or                                 '. 
Cause  of  Death 

>To. 
769 

Clainp 

2  pounds 

4  inches 

Recovered 

■Well  Dec.  1876.    No  report  since 

Clamp 

14      „ 

5      „ 

Died,  5th  day 

Septic  peritonitis 

770 

Clamp 

30      „ 

5      „ 

Recovered 

Well  in  1881 

771 

Ligature  . 

14       „ 

5      » 

Recovered 

Well  Nov.  1876.    No  report  since 

772 

Ligature  . 

24      „ 

5      „ 

Recovered 

Well  in  1881 

773 

Ligature.  Both 
ovaries 

13      „ 

5      „ 

Recovered 

WeU  Nov.  1876.    Died  in  1879— cancer 
of  kidney 

774 

Clamp     . 

IS      „ 

5      „ 

Recovered 

Well  in  1881 

775 

Ligature  . 

13      „ 

5      » 

Recovered 

Well  in  1881 

776 

Clamp 

10      „ 

5      „ 

Recovered 

Well   in  1881.     Works  in  telegraph 
office  '  as  well  as  any  there ' 

777 

Clamp 

19      „ 

5      ., 

Recovered 

Well  in  1881 

778 

Ligature  . 

5      „ 

5      „ 

Died,  4th  day 

Septicaemia 

779 

Clamp 

12      „ 

5      „ 

Died,  7th  day 

Peritonitis 

780 

Clamp     . 

24      „ 

4      „ 

Recovered 

Well  in  1881 

781 

Clamp     . 

23      „ 

5      „ 

Died,  6th  day 

Exhaustion 

782 

Ligature . 

5      » 

Died,  10th  day 

Peritonitis 

783 

Clamp 

43      „ 

6      „ 

Recovered 

Well  Dec.  1876.    No  report  since 

784 

Clamp 

9      » 

5      „ 

Recovered 

Well  in  1881 

785 

Clamp 

7      „ 

5       „ 

Recovered 

Well  in  1881 

786 

Clamp 

15      „ 

5      „ 

Recovered 

Well  in  1881 

787 

Clamp  and  liga- 
ture.     Both 
ovaries 

18      „ 

5      „ 

Recovered 

Well  in  1881 

788 

Ligature  . 

9      „ 

5      „ 

Recovered 

Seen  well  May  1878.    No  report  since 

789 

Ligature.  Both 
ovaries 

7      » 

5      „ 

Recovered 

Well  in  1881 

790 

Clamp 

7      „ 

5      „ 

Recovered 

Second  operation  Nov.  1881.    Well  in 
December 

791 

Ligature  . 

10      „ 

4      „ 

Recovered 

Well  in  1881 

792 

Clamp  and  liga- 
ture 

12      „ 

5      „ 

Recovered 

Well  in  1881.    Weighs  12  stones,  and 
walks  six  miles  a  day 

793 

Clamp 

12      „ 

5            !) 

Died,  14th  day 

Peritonitis 

794 

Clamp 

44      „ 

5      » 

Recovered 

Well  in  1881 

795 

Ligature.  Both 
ovaries 

16      „ 

5      „ 

Recovered 

Married  and  well  in  1881 

796 

Ligature  . 

9      » 

•5      „ 

Recovered 

Married  1880.    Well  in  1881 

797 

Clamp 

7      „ 

4      „ 

Recovered 

Pregnant  and  well  Dec.  1876 — girl  born 
April  1877.    Well  in  1881 

798 

Clamp 

31      „ 

4      „ 

Recovered 

Well  in  1881 

799 

Ligatures.  Both 
ovaries 

19      „ 

4      » 

Died  in  4  week? 

Peritonitis  and  tubercular  cavities  in 
lung 

800 

Ligature  . 

12      „ 

4      „ 

Recovered 

Well  in  1881 

801 

Clamp 

25      „ 

5      „ 

Recovered 

Died  Sept.  1878.    Cancer  of  liver 

802 

Clamp 

18      „ 

5      „ 

Recovered 

Married   1880— boy   1881.      Well    in 
December 

803 

Ligatures.  Botl 
ovaries 

11          M 

4       „ 

Recovered 

Well  in  1881 

804 

Ligatures.  Botl 
ovaries 

1C         „ 

5       „ 

Recovered 

No  report 

800 

damp 

12      „ 

5      » 

Recovered 

No  report 

800 

Ligatures 

10      „ 

5       „ 

Recovered 

No  report 

807 

384 


TABLE   OF   ONE   THOUSAND   CASES 


811 

812 
813 
814 

815 

816 
817 

818 
819 
820 

821 
822 

823 

824 

82-", 
826 

S27 


829 
830 
831 


833 
834 

835 
836 


840 
84] 

842 

843 

Ml 


Medical  Attendant 


Dr.  Paine,  Cardiff 

Hospital 

Dr.  Gage  Brown  . 


Hospital 
Hospital 
Hospital 
Dr.  Leadam . 

Hospital 


Mr.  E.  Barker 
Hospital 


Dr.  Oldham,  Brighton 

Hospital 

Mr.  Kingdon 


Hospital 

Mr.  Bishop,  Tonbridge 

Dr.  Priestley       .... 

Professor  Humphry,  Cambridge 

Hospital 

Dr.  Leslie,  Alton . 

Dr.  Paul 

Hospital 


Hospital      • 
Dr.  Brodie  Sewell 
Hospital 


Hospital 


Dr.  Godson  . 

Mr.  Carruthers,  Buncorn 


Hospital 

Dr.  Myrtle,  Harrogate 

Dr.  March,  Wandsworth 

Hospital 

Hospital 


Date 

of 

Operation 


Age 


Dr.  Nebel,  Heidelberg 
Dr.  Clark,  Dunster  . 
Hospital 


Dr.  Cazenove 
Hospital 


1876  Nov. 
„  Nov. 
„  Not. 

„  Nov. 

„  Nov. 

„  Nov. 

„  Nov. 

„  Dec. 

„  Dec. 

„  Dec. 

„  Dec. 

„  Dec. 

„  Dec. 

1877  Peb. 
„  Feb. 

„  Feb. 

„  Feb. 

„  Feb. 

„  Feb. 

„  Feb. 

„  Feb. 

„  March 

„  March 

„  March 

„  March 

„  March 

„  March 

„  March 

„  March 

„  March 

„  April 

„  April 

„  April 

„  April 

,,  April 


April 
May 


Condition 


Married 

Single 

Single 

Married 
Single 
Single 
Married 

Married 

Single 
Married 

Married 
Married 
Widow 

Married 
Single 

Married 

Single 

Married 

Married 

Single 

Married 

Married 
Married 
Married 

Widow 

Married 
Single 

Single 
Single 

Married 

Widow 

Married 

Married 

Single 

Single 

Single 
Married 


Adhesions 


Parietal.    Suppurating  cyst 

Parietal 

None 

Omental 

Omental 

Parietal  and  omental . 
Parietal 

Intestinal  and  pelvic  . 

Parietal  and  omental . 
Parietal.    Pregnant  . 

Parietal  and  omental . 
Parietal       .        .        .        . 
Pelvic 

None 

Omental 

Omental 

None 

Parietal,  intestinal,  and  omental 

Pelvic 

None 

Omental 

Parietal  aad  omental . 
Parietal  and  omental . 
Parietal 

Intestinal  and  omental 

None 

None 

Parietal 

Parietal  and  intestinal 

None 

None 

Pelvic 

Parietal  and  omental . 

Parietal,  omental,  and  vesical   . 

Parietal  and  omental 


None  .... 

Parietal  and  intestinal 


OF  COMPLETED   OVARIOTOMY 


385 


Treatment  of 
Pedicle 

Weight  of 
Tumour 

Length 

of 
Incision 

Result 

Subsequent  History 

or 

Cause  of  Death 

No. 
808 

Clamp 

19  pounds 

5  inches 

Recovered 

Well  in  1881 

Ligatures 

16      „ 

5      >, 

Recovered 

No  report 

809 

Ligature  . 

15      „ 

5       „ 

Recovered 

Married  in  1878.    Died  seven  months 
after.    Cancer  of  lung 

810 

Clamp 

24      ., 

5      „ 

Recovered 

No  report 

811 

Clamp 

28      „ 

5      .. 

Recovered 

Well  in  1881 

812 

Ligature  . 

25      „ 

5       „ 

Recovered 

Well  in  1881 

813 

Clamp 

11      » 

5      ,. 

Recovered 

Three  girls,  horn  1878-79-81.    Well  in 
1881 

814 

Ligature  . 

23      „ 

8      „ 

Recovered 

Girl  born  1879 — pregnant  and  well  in 
1881 

815 

Ligature  . 

13      „ 

5      » 

Recovered 

Well  in  1881 

816 

Ligature  . 

11      » 

5      „ 

Recovered 

Two  boys   born   1878-80.      Well   in 
1881 

817 

Clamp 

20      „ 

5      „ 

Recovered 

Well  in  1881 

818 

Clamp 

23      „ 

5      „ 

Recovered 

Well  in  1881 

819 

Ligature.  Both 
ovaries 

40      „ 

6      „ 

Recovered 

Well  in  1881 

820 

Ligature  . 

6      „ 

5      „ 

Recovered 

Well  in  1881 

821 

Ligature.  Both 
ovaries 

9      » 

5      » 

Recovered 

Well  in  1881 

822 

Clamp 

13      „ 

5      „ 

Recovered 

Three  children    since,   one    boy  two 
girls— born  1877-79-81.    Well 

823 

Clamp 

14      „ 

4      „ 

Recovered 

Well  in  1881 

824 

Ligature  . 

7      „ 

7      „ 

Recovered 

One  boy  in  1878.    Well  in  1881 

825 

Ligature  . 

16      „ 

5      » 

Died,  5th  day 

Septic  peritonitis 

826 

Clamp 

27      „ 

5      „ 

Recovered 

Well  in  1881 

827 

Clamp  and  liga- 
ture.     Both 
ovaries 

27      „ 

5      „ 

Recovered 

Well  in  1881 

828 

Ligature  . 

22      „ 

7      „ 

Recovered 

Well  in  1881 

829 

Ligature  . 

33      „ 

5      „ 

Recovered 

Died  in  1880.    Disease  of  liver 

830 

Ligature  . 

19      „ 

6      „ 

Recovered 

Died  a  few  years  after  of  malignant 
disease 

831 

Ligature  . 

9      „ 

5      „ 

Recovered 

Died  June  1880  of  colloid  disease  of 
peritoneum 

832 

Clamp 

15      „ 

4      „ 

Died,  5th  day 

Septicaemia 

833 

Ligatures.  Both 
ovaries 

5      „ 

Recovered 

Well  in  1881 — acting  as  schoolmistress 

834 

Ligature  . 

7      „ 

5       „ 

Recovered 

Died  of  bronchitis  in  1878 

835 

Ligature.  Both 
ovaries 

9      ,, 

5       „ 

Died,  5th  day 

Septicaemia 

836 

Ligature  . 

7      „ 

5      „ 

Recovered 

Died  of  cardiac  disease  Aug.  1877 

837 

C'larnp 

19      „ 

5      „ 

Recovered 

No  report 

838 

Ligature.  Both 
ovaries . 

28      „ 

6      „ 

Died,  5th  day 

Septicaemia 

839 

Ligature.  Both 
ovaries. 

32      „ 

5      „ 

Recovered 

Well  in  1881 

840 

Ligature.  Three 
ovarie  '.- 

21      „ 

5      „ 

Died,  10  hours 

Haemorrhage 

841 

Olampas 

ture.      Both 
ovarii-:. 

17      „ 

5      » 

Recovered 

Well  in  1881 

842 

i 

9      „ 

5      „ 

Recovered 

Well  in  1881 

843 

Olamp 

18      ., 

■r> 

;■.  revered 

Well  in  1881 

844 

c  c 


386 


TABLE   OF   ONE   THOUSAND   CASES 


sir, 


Medical  Attendant 


Hospital 


846  Hospital 

847  Dr.  Drake,  Exeter 
Dr.  Manson,  Chesterfield  . 

849    Mr.  Greaves,  Bishop's  Walthani 


S63 


Dr.  Stewart,  Glanlough 


Date 

of 

Operation 


1877  May 


Hospital      .        .        . 
Dr.  Beddoe,  Clifton    . 
Dr.  Webb    . 
Mr.  Coryn,  Brixton    . 
Hospital      .        •        .        . 
Dr.  Latham,  Cambridge    . 
Dr.  Drage,  Hatfield    . 
Hospital      .       •        • 
Dr.  Kinnear,  Malmesbury , 
Hospital      . 
Hospital  . 


Dr.  Hermann,  South  Africa 

Dr.  Lennard,  Clifton  . 
Mr.  Shaw,  Sheffield    . 
Hospital      .... 
Hospital      .... 


Dr.  Craig,  Montreal,  Canada 


Hospital 

Mr.  Winter,  Brighton 
Dr.  Aveling,  Clapton . 
Dr.  Tilley,  Brigg 
Dr.  Grant   . 


Hospital 

Mr.  Pratt,  Wivlescombe 

Hospital 

Hospital 

Dr.  Hadden,  Manchester 

Hospital 

Mr.  Stirling         . 


Hospital      . 

Dr.  Zanobini,  Genoa  . 

Mr.  J.  Murray,  Brighton 

Dr.  Cooper  Key  . 

Hospital      . 

Hospital 

Hospital 

Dr.  M.  Duncan    . 


May 
May 
June 
June 

June 

June 
June 
June 
June 
June 
June 
July 
July 
July 
July 
July 

July 

July 
July 

July 
July 

July 

Aug. 
Aug. 
Sept. 
Sept. 
Sept. 

Oct. 

Oct. 

Oct. 
,  Oct. 
,  Nov. 
,  Nov. 
i     Nov. 

i  Nov. 

,  Nov. 

,  Nov. 

,  Dec. 

,  Dec. 

,  Dec. 

,  Dec. 

,  Dec. 


Single 

Married 
Married 
Single 
Single 

Married 

Single 

Married 

Married 


Single 

Single 

Married 

Single 

Widow 

Married 

Married 

Married 

Married 
Widow 
Married 
Single 

Married 

Married 
Married 
Married 
Married 
Married 

Widow 

Single 

Married 

Single 

Single 

Single 

Married 

Married 

Married 

Widow 

Married 

Single 

Married 

Married 

Single 


None 


None 

Vesical 

None 

Parietal  and  omental .       . 

Parietal,  intestinal,  and  pelvic  , 


Parietal 

Parietal  and  omental. 

None   .... 

None  .... 

Omental 

None  .... 

None  .... 

Omental      . 

None   .... 

Parietal 

Parietal  and  omental . 


None 


Parietal,  omental,  and  intestinal 
Parietal,  omental,  and  hepatic  . 

Omental 

Mesenteric 


Omental  and  parietal . 


None  . 
Parietal 
None  . 
Omental 
Intestinal 


None    . 

Parietal 

Omental 

Parietal  and  omental . 

None    . 

None    . 

None.    Pregnant 


Pelvic 

None    . 

Omental 

Parietal 

None    ... 

Omental  and  parietal 

Omental  and  parietal 

Intestinal     . 


I 


OF  COMPLETED    OVARIOTOMY 


387 


Treatment 

of 

Pedicle 

Weight  of 
Tumour 

Length 

of 
Incision 

Result 

Subsequent  History 

or 

Cause  of  Death 

No. 

845 

Clamp 

16  pounds 

5  inches 

Recovered 

Married   in    1879— miscarriage    1880. 
Well  in  1881 

Clamp 

27      „ 

5      „ 

Recovered 

Well  in  1881 

846 

Clamp 

10      „ 

5      „ 

Recovered 

Died — cancer. 

847 

Ligature  . 

29      „ 

4      „ 

Recovered 

No  report 

848 

Ligature.  Both 
ovaries 

15      „ 

4      „ 

Died,  36  hours 

Hemorrhage 

849 

Forceps      and 
ligature 

10      „ 

5      » 

Died,  63  hours 

Septicaemia 

850 

Clamp 

7      „ 

4      „ 

Recovered 

Well  in  1881 

851 

Clamp 

19      „ 

5      „ 

Recovered 

Well  in  1881 

852 

Ligature  . 

17      „ 

5      „ 

Recovered 

Well  in  1881 

853 

Clamp 

28      „ 

4      „ 

Recovered 

No  report 

854 

Ligature  . 

10      „ 

5      „ 

Recovered 

Well  in  1881 

855 

Clamp 

13      „ 

5      „ 

Recovered 

Well  in  1881 

856 

Ligature  . 

13      „ 

6      „ 

Recovered 

Well  in  1881 

857 

Clamp 

12      „ 

5      „ 

Died,  5th  day 

Septicaemia 

858 

Clamp 

17      „ 

5      „ 

Recovered 

Well  in  1881 

859 

Clamp 

21      „ 

5      „ 

Recovered 

One  child  since.    Well  in  1881 

860 

Clamp 

8      „ 

6      „ 

Recovered 

Two  children  since  operation.     Well 
in  1881 

861 

Clamp 

6      „ 

Recovered 

Returned  to  Africa.    Well  when  last 
heard  of 

862 

Clamp 

11      » 

5      » 

Died,  56  hours 

Peritonitis 

863 

Clamp 

5      „ 

Died,  8th  day 

Peritonitis 

864 

Ligature . 

13      „ 

9      „ 

Recovered 

No  report 

865 

Ligature.  Both 
tubes 

6      „ 

6      „ 

Recovered 

Married  in  1878.    Well  in  1881 

866 

5      „ 

Recovered 

Child   born    1880,    after    return    to 
Canada.    Well  in  1881 

867 

Clamp      .  ■    . 

35      „ 

6      „ 

Recovered 

No  report 

868 

Clamp 

5      „ 

Recovered 

Well  in  1880 

869 

Clamp 

15      „ 

5      „ 

Recovered 

Well  in  1881 

870 

Ligature . 

7      „ 

5      „ 

Recovered 

Well  in  1881 

871 

Ligature.  Both 
ovaries 

20      „ 

5        M 

Died,  3rd  day 

Septic  peritonitis 

872 

Clamp 

33      „ 

5      „ 

Recovered 

Well  in  1881 

873 

Clamp 

78      „ 

5      „ 

Died,  3rd  day 

Septicaemia 

874 

Clamp 

18      „ 

5      » 

Died,  5th  day 

Septicaemia 

875 

Clamp 

29      „ 

5       » 

Recovered 

WeU  in  1881 

876 

5      „ 

Died,  8th  day 

Septicasmia 

877 

Clamp 

23      „ 

5      „ 

Recovered 

Well  in  1881 

878 

Clamp 

10      „ 

4      „ 

Recovered 

Three  children  born  since.    Well  in 
1881 

879 

Ligature  . 

26      „ 

5      „ 

Recovered 

Well  in  1881 

880 

Clamp 

19      „ 

5      » 

Recovered 

Well  in  1881 

881 

Ligature  . 

21      „ 

5      ,, 

Died,  14th  day 

Peritonitis.    Cancer 

882 

Clamp 

17      „ 

5      „ 

Recovered 

Well  in  1880 

883 

Clamp 

13      „ 

5       » 

Recovered 

Married  1878.    Well  in  1881 

884 

Clamp 

16      „ 

5      ,, 

Recovered 

Well  in  1881 

885 

Clamp 

12      „ 

5      „ 

Recovered 

Girl  born  1880.    Well  in  1881 

886 

Died,  9th  day 

Septicaemia 

887 

c  c  2 


388 


TABLE    OF    ONE  THOUSAND  CASES 


890 

891 
892 
893 


895 
896 
897 
898 
899 
900 
90] 
902 
903 

904 
905 

906 

907 

908 
909 
910 
911 

912 
913 


915 
916 
917 

918 
919 
920 

921 
922 
923 
924 
925 

926 

927 


Medical  Attendant 


Dr.  Frank,  Cannes     . 

Mr.  Gilbert,  Hackney 
Dr.  Mallett,  Bolton    • 

Dr.  Carpenter,  Croydon 

Mr.  Clover  . 

Mr.  Morgan 

Dr.  Cohn,  Hamburg  . 

Dr.  Way      . 

Mr.  Robinson,  Huddersfield 
Dr.  Edith  Pechey,  Leeds 
Dr.  Brown,  Rochester 
Mr.  Johnston,  Leicester 
Sir  Risdon  Bennett 
Dr.  Ferguson,  Belfast 
Dr.  F.  Farre 
Mr.  Treves,  Margate   . 

Mr.  Marshall,  Birmingham 
Mr.  Hayes,  Tittensor  . 


Mr.     C.    Hawkins,      Chelten 
ham 

Mr.  Hanks,  Snaith     . 

Mr.  Carver,  Fulham    . 
Dr.  Walters,  Reigate  . 
Dr.  Cronin  .... 
Dr.  Jack,  Hampton  Court 


Dr.  Cumming,  Belfast 
Mr.  Manley  Sims 

Mr.  Cheyne . 

Mr.  Evershed,  Hampstead 
Mr.  Collambell    . 
Dr.  Sanderson     . 

Dr.  C.  Pearce,  Brixton 

Dr.  Bell,  Preston 

Dr.  Rooke,  Cheltenham 

Dr.  Priestley 

Dr.  Duke,  Norwood    . 

Mr.  T.  Smith 

Dr.  Holman,  Reigate  . 

Mr.  Knaggs,  Huddersfield 

Mr.  Riddle,  Leamington 
Mr.  Covey.  Alresford  . 


Date 

of 

Operation 

Age 

1878  Jan. 

49 

„     Feb. 

60 

„     Feb. 

29 

„     Feb. 

41 

„     Feb. 

44 

„     Marcli 

63 

„     April 

21 

„     April 

52 

„     May 

56 

„     May 

22 

„     June 

22 

„     June 

24 

„     June 

57 

„     June 

31 

„     June 

63 

„     June 

68 

„     July 

68 

„     July 

33 

>i     July 

42 

„     July 

42 

„     Aug. 

40 

„     Aug. 

„     Aug. 

61 

„     Aug. 

63 

„     Sept. 

38 

„     Oct. 

27 

„     Oct. 

50 

„     Oct. 

58 

„     Oct. 

46 

„    Nov. 

40 

„    Nov. 

59 

„    Nov. 

46 

„    Nov. 

„    Dec. 

61 

„    Dec. 

51 

1S79  Jan. 

32 

„    Jan. 

19 

„    Feb. 

46 

„     Feb. 

59 

.,    Feb. 

60 

Condition 


Widow 
Married 

Single 
Widow 
Single 
Married 

Single 

Widow 

Single 

Married 

Married 

Married 

Single 

Single 

Married 

Single 
Single 

Married 

Single 

Married 
Married 
Widow 
Single 

Married 
Married 

Single 

Widow 
Married 
Single 

Widow 
Married 
Married 

Married 

Married 

Married 

Single 

Married 

Married 
Silicic 


Adhesions 


None 

None 

Omental.    Burst  cyst . 

Parietal  and  omental  . 
None.    Burst  cyst 

None 

None    ...... 

None 

Omental.    Burst  cyst 

Parietal 

Omental 

None 

None 

Pelvic 

None 

None 

Intestinal 

Cffical  ...... 

None 

None 

None 

Parietal  and  omental  . 
Parietal.     Suppurating  cyst 
Parietal 

Omental  and  intestinal 

Parietal  and  intestinal.      Burst 
cyst 

None 

None 

Intestinal 

Omental,  parietal,  and  pelvic     . 

Parietal  and  mesenteric 
Parietal  and  intestinal       . 
Parietal 

Parietal  and  intestinal 
Parietal  and  intestinal 

None 

None 

Parietal  and  omental . 

None 

None 


! 


OF   COMPLETED    OVARIOTOMY 


389 


Treatment  oi 
Pedicle 

Weight  of 
Tumour 

Length 

of 
Incision 

1        Besults 

Subsequent  History 

or 

Cause  of  Death 

No. 

888 

Ligature.'  Bot 
ovaries  (Bat 
tey) 

i     •■ 

3  inches 

Becovered 

Well  in  1881 

Ligature . 

23  pounds 

5      „ 

Recovered 

Died  in  1879. 

889 

6      „ 

Recovered 

Died  of  malignant  disease  (general) 
June  1878 

890 

6      „ 

Recovered 

Well  in  1881 

891 

Recovered 

Died  of  phthisis  in  1879 

892 

Ligature  . 

•       22      „ 

5      », 

Recovered 

Well  in  1880 

893 

Ligature.  Bot] 

i     .        i 

5      » 

Recovered 

Well  in  1881 

894 

ovaries 

Ligature . 

15      „ 

5      „ 

Recovered 

Well  in  1880 

895 

Ligature . 

9      ,. 

4      „ 

Recovered 

Well  in  1881 

89G 

Ligature . 

23      „ 

5      „ 

Recovered 

Well  in  1881 

897 

Ligatures 

8      „ 

4      „ 

Died,  7th  day 

Tetanus 

898 

Ligatures 

8      „ 

4      „ 

Recovered 

Well  in  1881 

899 

Ligatures 

18      „ 

5      ,, 

Recovered 

Well  in  1881 

9H0 

Ligatures 

10      „ 

5      » 

Recovered 

Well  in  1881 

901 

Ligatures 

18      „ 

5      >■ 

Died,  4th  day 

Septicaemia 

902 

Ligatures.  Bot 

h   . 

5      „ 

Recovered 

Died  in  1879. 

903 

ovaries 

5      „ 

Recovered 

Died  in  1880— cancer 

904 

Ligature  . 

33      „ 

4      „ 

Recovered 

Married  since — two  children     Well  in 
1881 

905 

5      „ 

Recovered 

Two  children  since.    Well  in  1881 

906 

Ligatures 

18      „ 

3      „ 

Recovered 

Died  of  peritonitis  in  1880  after  expo- 
sure to  cold 

907 

Ligatures 

7      „ 

5      „ 

Recovered 

Well  in  1881 

908 

Ligature  . 

12      „ 

6      » 

Recovered 

Well  in  1881 

909 

Clamp 

31      „ 

6      „ 

Recovered 

Well  in  1881 

910 

Ligature.  Both 

31      „ 

5      „ 

Died,  7th  day 

Septicaemia 

911 

ovaries 

Ligature . 

22      „ 

6      „ 

Recovered 

Well  in  1880 

912 

6      „ 

Recovered 

Well  in  1881 

913 

Ligature.  Both 

4      „ 

Recovered 

Well  in  1881 

914 

ovaries 

Ligature  . 

22      „ 

6      .. 

Recovered 

Well  in  1881 

915 

5      » 

Recovered 

Well  in  1881 

916 

Ligature  . 

15      „ 

6      „ 

Recovered 

Died  after  removal  of  foreign  body 
from  bladder 

917 

Ligatures 

63      „ 

6      „ 

Died,  4th  day 

Bronchitis 

918 

5      „ 

Recovered 

Well  in  1881 

919 

Ligature.  Both 

11      » 

5      „ 

Recovered 

Well  in  1881 

920 

ovaries 

Ligature  . 

21      „ 

5      » 

Recovered 

Well  in  1881 

921 

Ligature  . 

16      „ 

5      „ 

Recovered 

Well  in  1881 

922 

Recovered 

Well  in  1881 

923 

Ligature  . 

16      „ 

4      „ 

Recovered 

Married  and  well  in  1881 

924 

. 

5      „ 

Died,  7th  day 

Obstructed  intestine 

925 

ovaries 

U<.';it,iiri:-: 

16      „ 

■r>      ,, 

Recovered 

Well  in  1881 

926 

Ligature  . 

16      „ 

■>      „ 

Kcr.ovi-l'CiJ 

Well  in  1881 

927 

390 


TABLE   OF   ONE   THOUSAND   CASES 


Medical  Attendant 


928 

929 
930 
931 
932 
933 

934 

935 
936 

937 


939 
940 
941 
942 
943 

944 

945 


947 

948 

949 
950 

951 
952 

953 

954 
955 
956 

957 

958 
959 


961 
962 

963 
964 
965 
966 
967 
968 


Dr.  Lee,  Hull 

Dr.  Marion  Sims . 

Dr.  F.  Weber      . 

Dr.  McDonnell,  Dublin 

Dr.  Greenidge,  Barbadoes 

Mr.  Bell,  New  Brighton 

Mr.  Parsons,  Frome  . 
Mr.  Bishop,  Tonbridge 
Dr.  Waller,  Sydenham 
Dr.  Jackson,  Southsea 

Mr.  Bickersteth,  Liverpool 

Dr.  Matheson 
Dr.  Paget,  Cambridge 
Mr.  Whitling,  Croydon 
Dr.  Kidd,  Dublin 
Dr.  O'Connor 


Dr.  Higginbotham,  St.  Peters 
burg 

Dr.  Glover  .... 

Dr. ,  Moscow 

Mr.  Keetley,  Grimsby 

Dr.  Hunter,  Matlock . 
Mr.  Chapman,  Tooting 
Mr.  Purner,  Brighton 
Mr.  Newstead,  Clifton 
Mr.  Hewetson,  York  . 

Mr.  Johnson,  Bedford 
Dr.  H.Weber     . 
Dr.  Muller,  Norwood 
Dr.  Stokes,  Highbury 

Dr.  Aitken,  Netley     . 

Mr.  Pocklington,  Wimbledon 

Dr.  Liddon,  Taunton  . 

Dr. ,  Barbadoes    . 

Dr.  Macconchy,  Downpatrick 

Dr.  Bezley  Thome 

Dr.  Weil,  Basle   . 

Dr.  Blaxall .... 

Dr.  Parson,  San  Francisco 

Mr.  James,  Uxbridge 

Dr.  G.  Anderson 


Date 

of 

Operation 


Age 


1879  Feb. 


Condition 


42       Single 


Feb. 

45 

Married 

March 

51 

Single 

March 

36 

Single 

March 

19 

Single 

March 

39 

Single 

March 

59 

Widow 

March 

19 

Single 

April 

32 

Married 

April 

68 

Single 

April 

52 

Single 

May 

41 

Married 

May 

54 

Married 

May 

47 

Married 

May 

34 

Single 

May 

60 

Married 

May 

28 

Single 

May 

36 

Married 

May 

61 

Married 

May 

24 

Married 

May 

20 

Single 

June 

32 

Single 

June 

62 

Single 

June 

33 

Single 

June 

51 

Single 

June 

38 

Married 

July 

28 

Single 

July 

50 

Married 

July 

13 

Single 

Aug. 

Married 

Aug. 

26 

Single 

Sept. 

44 

Widow 

Sept. 

44 

Widow 

Sept. 

36 

Married 

Sept. 

48 

Single 

Oct. 

63 

Widow 

Oct. 

55 

Married 

Oct. 

59 

Married 

Oct. 

39 

Single 

Oct. 

25 

Single 

Nov. 

50 

Single 

Adhesions 


None 

Csecal 

None.    Burst  colloid  . 

None 

Parietal  and  omental . 
Omental  and  intestinal 

None 

Omental 

Parietal 

None 

None.    Fallopian  papilloma,  as- 
cites 
Parietal  and  intestinal 

None 

Pelvic 

None    ...... 

Parietal,  omental,  and  pelvic     . 

None 

Parietal 

Omental 

Parietal  and  intestinal 

Pelvic.    Burst  cysts  . 

None 

None 

None 

None 

Pelvic 

None 

None 

None 

None 

None 

Omental 

Parietal,    omental,    and    intes- 
tinal 

None   ...  .       . 

Intestinal 

Omental 

None 

None 

None.    Dermoid 

None 

None.    Burst  cyst 


OF   COMPLETED    OVARIOTOMY 


391 


Treatment 

of 

Pedicle 

Weight  of 
Tumour 

Length 

of 
Incision 

Besult 

Subsequent  History 

or 

Cause  of  Death 

Ligature.  Both 
ovaries 

19  pounds 

5  inches 

Recovered 

Well  in  1881 

Ligature  . 

7      » 

5      .. 

Recovered 

Well  in  1881 

5      „ 

Recovered 

Well  in  1881 

4      „ 

Recovered 

Well  in  1881 

Ligature .        . 

14      „ 

6      „ 

Recovered 

Well  in  1881 

Ligature.  Both 
ovaries 

11      ., 

6      „ 

Died,  4th  day- 

Septicaemia 

Ligature  . 

9      » 

5      „ 

Recovered 

Well  in  1881 

Ligature  . 

16      „ 

5      „ 

Recovered 

Well  in  1881 

Ligature . 

18      „ 

6      „ 

Recovered 

Well  in  1881 

Ligature . 

15  fibroma, 
26  ascites 

10      „ 

Recovered 

Well  in  1881 

4      „ 

Recovered 

WeU  in  1881 

8      „ 

Recovered 

Well  in  1881 

6      » 

Recovered 

Well  in  1880 

6      „ 

Recovered 

Well  in  1880 

Ligature  . 

25      „ 

6      » 

Recovered 

Well  in  1881 

Ligature.  Both 
ovaries 

47      „ 

5      „ 

Recovered 

Died  4  months  after  operation  of  bron- 
chitis 

Ligature  . 

16      „ 

4      „ 

Recovered 

No  report 

8      „ 

Recovered 

No  report 

Ligature.  Both 
ovaries 

20      „ 

6         5, 

Recovered 

WeU  in  1881 

Ligature.  Both 
ovaries 

10      „ 

6      » 

Recovered 

WeU  in  1880 

Ligature.  Both 
ovaries 

20      „ 

5      „ 

Recovered 

Well  in  1881 

Ligature  . 

19      » 

5      » 

Recovered 

WeU  in  1881 

Ligature .       . 

13      „ 

6      „ 

Recovered 

WeU  in  1881 

Ligature . 

14      „ 

4      „ 

Recovered 

Well  in  1881 

4      „ 

Recovered 

Well  in  1881 

Ligature.  Both 
ovaries 

10      „ 

5      „ 

Recovered 

WeU  in  1881 

Ligature . 

10      „ 

6      „ 

Recovered 

WeU  in  1880 

Ligature  . 

28      „ 

6      „ 

Recovered 

WeU  in  1880 

Ligature . 

8      u 

5      „ 

Recovered 

WeU  in  1881 

Ligature.  Both 
ovaries 

13      „ 

6      „ 

Recovered 

Died  1880— phthisis 

Ligature . 

15      „ 

5      „ 

Recovered 

WeU  in  1881 

Ligature . 

32      „ 

6      ., 

Recovered 

WeU  in  1881 

Ligature . 

7      » 

5      „ 

Recovered 

WeU  in  1881 

Ligature  . 

18      „ 

6      „ 

Recovered 

No  report 

Ligature.  Both 
ovaries 

19      „ 

5      „ 

Recovered 

No  report 

Ligature . 

7      „ 

8      „ 

Recovered 

No  report 

Ligature . 

10      „ 

5      „ 

Recovered 

WeU  in  1881 

Ligature . 

13      „ 

5      „ 

Recovered 

WeU  in  1880 

Recovered 

WeU  in  1881 

5       „ 

Recovered 

Well  in  1881 

Ligature  .        . 

5       „ 

Recovered 

Well  in  1881 

392 


TABLE   OF   ONE   THOUSAND  CASES 


Medical  Attendant 


Dr.  Wilberforce  Smith 
Mr.  Square,  Plymouth 
Mr.  Douglas,  Hounslow 
Mr.  Archibald,  Brixton 
Dr.  Sheehy  . 
Mr.  Lund,  Manchester 
Mr.  J.  Murray,  Brighton 
Mr.  Bubb,  Cheltenham 

Dr.  Broxholm     . 


Dr.  W.  Roberts,  Manchester 
Sir  Bisdon  Bennett     . 


Mr.  Haffenden    . 

Mr.  Dodd,  Slough 

Mr.  Robey,  Wandsworth 

Dr.  Reed,  Manchester 

Dr.  Priestley 

Dr.  Priestley 

Dr.  England,  Winchester 

Dr.  Priestley 

Dr.  P6an,  Paris   . 

Dr.  MacSwiney,  Dublin 

Mr.  Harper,  Holbeach 
Mr.  Townshend  . 


Mr.  Pocklington,  Wimbledon 
Dr.  Garrett  Anderson 
Mr.  Frost,  Williton    . 
Mr.  W.  Adams    . 
Mr.  Bubb,  Cheltenham 

Dr.  Stephens,  Brighton 
Mr.  Clifton 
Dr.  Whitehead,  Manchester 
Dr.  Priestley     . 


Date 

of 

Operation 


1879  Nov. 
„  Nov. 
„  Nov. 
„  Dec. 
„  Dec. 
„  Dec. 
„    Dec. 

1880  Jan. 

„    Jan. 

„    Jan. 
,,    Jan. 


Feb. 
Feb. 
Feb. 

March 


Condition 


Adhesions 


marcn 

March 

30 

March 

58 

March 

53 

March 

45 

April 

35 

April 

49 

April 

May 

61 

May 

63 

May 

49 

May 

62 

May 

29 

May 

52 

May 

35 

June 

46 

June 

42 

Single 

Single 

Single 

Widow 

Married 

Married 

Married 

Single 

Married 

Single 
Single 


Married 

Single 

Married 

Married 

Married 

Married 

Married 

Married 
Married 
Married 

Married 
Single 

Married 

Single 

Married 

Widow 

Single 

Married 
Married 
Widow 
Married 


JNone    ...... 

None 

Parietal,  omental,  and  pelvic 

Omental       .... 

None    ..... 

None 

None 

Parietal  and  omental.    Suppu 
rating  cyst. 

Parietal,  omental,  and  pelvic 

None 

None 


None.    Burst  colloid  . 

Parietal  and  intestinal 

Parietal  and  omental . 

Intestinal.    Burst  cyst 

None 

None.    Burst  cyst 

Intestinal  and  mesenteric.  Can 
cer. 

Pelvic 

Parietal  and  omental . 

Parietal  and  omental . 


None    ...... 

Parietal  and  intestinal.    Burst 
cyst 

Parietal  and  omental . 

Omental 

Omental  and  intestinal 

None 

Omental,  intestinal,  and  pelvic . 

Omental  and  intestinal 
Parietal  and  omental . 
Omental  and  pelvic  . 
Omental  and  cascal     . 


OF  COMPLETED   OVARIOTOMY 


393 


Treatment  of 
Pedicle 

Weight  of 
Tumour 

Length 

of 
Incision 

Result 

Subsequent  History 

or 

Cause  of  Death 

No. 

Ligature  . 

16  pounds 

4  inches 

Becovered 

Well  in  1881 

969 

4      „ 

Recovered 

Well  in  1881 

970 

Ligature  . 

25      „ 

6      „ 

Recovered 

Well  in  1881 

971 

Ligature  . 

9      ., 

4      „ 

Recovered 

Well  in  1881 

972 

Ligature  . 

15      „ 

5      ,, 

Recovered 

Well  in  1881 

973 

Ligature  . 

10      „ 

4      „ 

Recovered 

Well  in  1881 

974 

Ligature  . 

17      „ 

5      ,, 

Died,  5th  day 

SepticEemia 

975 

Ligature  . 

22      „ 

5      „ 

Recovered 

Well  in  1881 

976 

Ligature.  Both 
ovaries 

5      „ 

Recovered 

Died  August  1880  of  cancer  of  uterus 

977 

Ligature  . 

24      „ 

5      » 

Died,  5th  day 

Bronchitis 

978 

Ligature  . 

7  lbs.  ova- 
rian ;  2  lbs. 
uterine  fib- 
roma. 

5      „ 

Recovered 

Well  in  1881 

979 

Ligature  . 

50      „ 

5      ,, 

Recovered 

Remains  well  1881 

980 

Ligature . 

16      „ 

5      » 

Recovered 

Well  in  1881 

981 

Ligature  . 

22      „ 

5      „ 

Recovered 

Well  in  1881 

982 

Ligature  . 

11      » 

5      ., 

Recovered 

Remains  well 

983 

Ligature  . 

6      „ 

5      ,» 

Recovered 

Well  in  1881 

984 

Ligature  . 

14      „ 

4      „ 

Recovered 

Well  and  a  child  born  1881 

985 

Ligature  . 

7      „ 

5      ., 

Died,  21  hours 

Embolism 

986 

Ligature  . 

5      „ 

5      „ 

Died,  24  hours 

Embolism 

987 

No  pedicle 

19      „ 

5      „ 

Recovered 

Remains  well  in  1881 

988 

Ligature  . 

21      „ 

5      „ 

Recovered 

Remains  well  in  1881.    Two  miscar- 
riages since  operation  ;   now  preg- 
nant 

989 

Ligature  . 

31      „ 

5      ,» 

Recovered 

Remains  well  in  1881 

990 

Ligature.  Both 
ovaries 

5      „ 

Died,  3rd  day 

Septicemia 

991 

Ligature  . 

40      „ 

5      „ 

Recovered 

Remains  well 

992 

Ligature  . 

17      „ 

5      „ 

Recovered 

Remains  well  in  1881 

993 

Ligature  . 

15      „ 

5      „ 

Died,  19th  day 

Intestinal  obstruction 

994 

Ligature . 

20      „ 

5      „ 

Recovered 

Remains  well  in  1881 

995 

Ligature.  Both 
ovaries 

15      „ 

5      „ 

Recovered 

Remains  well  in  1881 

990 

Ligature . 

20      „ 

5      „ 

Recovered 

Remains  well  in  1881 

997 

Ligature  . 

17      „ 

5      „ 

Recovered 

Remains  well  in  1881 

998 

Ligature  . 

12      „ 

5      „ 

Recovered 

Remains  well 

999 

Ligature . 

12      „ 

5      „ 

Recovered 

Remains  well  in  1881 

1000 

394  CASE   OF   OVARIOTOMY   PERFORMED 


CHAPTER  XI. 

ON   OVARIOTOMY  PERFORMED   TWICE   ON  THE  SAME  PATIENT 

The  first  patient  upon  whom  I  performed  ovariotomy,  one 
ovary  having  been  previously  removed,  had  been  operated  on 
by  Mr.  Baker  Brown  six  months  before  she  consulted  me  on 
account  of  a  recurrence  of  the  disease.  The  paper  in  which  I 
described  this  case  was  read  before  the  Medical  and  Chirurgical 
Society  in  June  1863,  and  appears  in  the  *  Transactions '  for 
that  year.  The  following  paragraphs  are  quotations  from  that 
paper : — 

'  In  November  1862  I  was  consulted  by  a  married  woman, 
forty-two  years  of  age,  from  whom  an  ovarian  tumour  had  been 
removed  six  months  before  by  another  surgeon.  She  left  the 
institution  in  which  ovariotomy  was  performed  three  weeks 
after  the  operation ;  but  about  a  week  after  going  home  she 
became  sick,  and  noticed  an  enlargement  on  the  right  side  of 
the  abdomen.  She  consulted  Sir  Charles  Locock,  who  had 
seen  her  before  the  first  operation,  and  who  told  her  that 
another  tumour  was  growing.  Sir  Charles  saw  her  again  in 
October,  told  her  that  the  tumour  was  increasing,  and  advised 
her  to  wait  about  three  months  before  having  a  second  opera- 
tion performed. 

i  When  she  came  to  me  I  was  not  aware  that  ovariotomy 
had  ever  been  performed  twice  on  the  same  patient.  A  case 
had  been  recorded  in  America  where  one  surgeon  had  attempted 
to  remove  an  ovarian  tumour,  but  failed  in  his  attempt,  and 
another  surgeon  had  afterwards  succeeded.  But  I  could  find 
no  case  on  record  in  which  a  patient  had  recovered  after  ovari- 
otomy, and  had  afterwards  undergone  the  operation  a  second 
time  on  account  of  disease  of  the  remaining  ovary.  I  was, 
therefore,  very  anxious  to  obtain  the  opinion  of  eminent  men 
respecting  this  patient,  and  I  believe  that  several  who  saw  her 


TWICE   ON   THE   SAME   PATIENT  395 

with  me  looked  upon  the  case  as  unprecedented.  But  I  have 
since  learned  that  Dr.  Atlee,  of  Philadelphia,  has  performed 
ovariotomy  successfully  upon  a  patient  from  whom  Dr.  Clay,  of 
Manchester,  had  removed  an  ovarian  tumour  of  the  opposite 
side  sixteen  years  before. 

i  When  the  patient  first  consulted  me  the  tumour  filled  the 
greater  part  of  the  abdomen  below  the  level  of  the  umbilicus. 
On  the  right  side  it  was  elastic  and  obscurely  fluctuating,  while 
on  the  left  side  it  was  very  hard.  The  uterus  seemed  to  be 
closely  connected  with  the  hard  tumour  on  the  left  side. 

'  I  communicated  with  Sir  Charles  Locock  upon  all  the  im- 
portant points  of  the  case,  and  proposed  to  make  an  exploratory 
incision,  and  to  be  guided  by  the  connection  of  the  tumour  as 
to  further  proceedings.  Sir  Charles  approved  of  this  sugges- 
tion, and  added,  "  The  operation  affords  the  only  hope  of 
relief." 

'  Before  proceeding  to  operate,  I  considered  whether  it  would 
be  better  to  make  the  incision  through  the  linea  alba — that  is, 
within  an  inch  of  the  cicatrix — or  in  one  of  the  linese  semi- 
lunars. But  as  there  was  some  doubt  whether  the  tumour 
was  a  growth  from  the  right  ovary,  or  a  growth  of  some  portion 
which  had  not  been  removed  from  the  left  side — in  other  words, 
whether  the  uterus  was  pulled  or  pushed  to  the  right  side — it 
appeared  to  be  safer  to  cut  in  the  meridian  line  than  to  run  any 
risk  of  making  the  incision  on  the  side  opposite  to  the  uterine 
attachment. 

'I  performed  the  operation  on  January  13,  1863.  Mr. 
Clover  administered  chloroform,  and  I  was  ably  assisted  by 
Dr.  Savage,  Dr.  Drage,  of  Hatfield,  and  Mr,  Webb,  of  Welwyn. 
I  made  an  incision  over  the  linea  alba,  three  quarters  of  an 
inch  to  the  left  of  the  cicatrix,  and  parallel  with  the  lower  four 
inches  of  it.  On  dividing  the  peritoneum,  the  tumour  was 
seen  to  be  composed  of  very  thin-walled  cysts,  very  tensely 
distended  with  clear  fluid.  These  cysts,  or  rather  divisions  of 
a  multilocular  cyst,  passed  successively  through  the  opening  in 
the  abdominal  wall  as  Dr.  Savage  pressed  the  tumour  from 
behind  forwards.  Several  filmy  layers  of  organised  lymph  and 
a  layer  of  expanded  omentum  were  pressed  outwards  before  the 
cyst,  and  were  divided  on  a  director.  A  piece  of  omentum 
which  adhered  both  to  the  cyst  and  to  the  abdominal  wall  near 


396  DETAILS  AND   RESULT 

the  upper  part  of  the  incision  was  easily  separated,  and  the 
tumour  was  then  pressed  out  entire,  without  emptying  any  of 
the  cysts.  The  pedicle  was  short,  but  it  was  easily  secured  by 
a  clamp.  It  passed  in  the  usual  manner  from  the  right  side  of 
the  uterus.  The  uterus  seemed  to  be  of  natural  size.  No 
remnant  of  the  left  ovary  was  found.  After  cutting  away  the 
tumour,  there  was  some  oozing  of  blood  around  the  clamp, 
but  it  was  stopped  by  tying  a  ligature  tightly  round  the  pedicle 
beneath  the  clamp.  One  bleeding  vessel  in  the  abdominal 
wall,  and  two  in  the  omentum,  were  also  tied,  Just  above 
the  upper  angle  of  the  wound  a  long  coil  of  small  intestine 
adhered  firmly  to  the  abdominal  wall.  As  the  patient  had 
complained  of  pain  at  this  spot,  and  had  suffered  from  consti- 
pation ever  since  the  first  operation,  I  examined  the  connec- 
tion between  the  intestine  and  the  abdominal  wall  to  see  if 
they  could  be  separated  safely;  but  the  adhesions  appeared 
to  be  so  very  close  that  I  did  not  attempt  to  effect  any  sepa- 
ration. The  wound  was  closed  by  deep  and  superficial  silk 
sutures. 

1  The  cyst  is  placed  on  the  table  of  the  Society.  It  is  a 
good  specimen  of  what  is  known  as  the  compound  proliferous 
cyst ;  and  it  is  curious  that  the  small  groups  of  minute  cysts  not 
only  grow  into  the  cavity  of  the  parent  cyst,  or  project  inwards, 
but  also  perforate  the  cyst- wall  and  project  into  the  peritoneal 
cavity. 

*  The  patient  rallied  remarkably  well  after  the  operation, 
and  for  forty-eight  hours  seemed  to  be  recovering.  Two  small 
opiates  were  given  on  account  of  pain,  but  reaction  was  not 
excessive.  The  aspect  was  good;  and  the  tongue,  though 
white,  was  moist.  The  pulse  was  about  100.  I  removed 
the  clamp  forty-four  hours  after  operation,  as  it  seemed  to  be 
lying  quite  loose  on  the  wound ;  the  ligature  which  had  been 
tied  beneath  it  also  came  away  with  a  shred  of  dead  fibrous 
tissue.  There  was  no  bleeding.  I  also  removed  three  of  the 
sutures. 

1  On  the  1 6th,  the  third  day  after  operation,  there  was  some 
flatulent  distension  of  the  abdomen,  and  frequent  eructation, 
but  no  vomiting.  The  rectum  was  cleared  by  an  enema.  At 
9  p.m.,  during  one  of  the  "  fits  of  belching,"  as  the  nurse  called 
them,  the  lower  part  of  the  wound  gave  way,  and  a  knuckle  of 


OF  THE  SECOND  OPERATION  397 

intestine  protruded.  A  good  deal  of  fetid  serum  also  escaped. 
I  returned  the  intestine,  reapplied  three  sutures  deeply,  and 
the  patient  did  not  seem  to  be  worse. 

'  On  the  next  day,  the  17th,  there  was  free  fetid  discharge 
from  the  lower  part  of  the  wound,  and  vomiting  became 
troublesome;  but  the  pulse  was  not  more  than  110,  and  the 
aspect  was  good. 

'  On  the  18th,  the  pulse  had  risen  to  120,  but  the  tongue 
was  moist  and  cleaning  from  the  edges,  and  the  colour  of 
cheeks  and  lips  very  good.  Still  she  was  decidedly  weaker, 
and  the  tympanites  was  increasing. 

'  She  continued  to  become  weaker  all  the  next  day,  notwith- 
standing the  free  use  of  stimulants  and  nourishment  both  by 
the  mouth  and  the  rectum ;  and  she  died  on  the  seventh  day, 
or  154  hours  after  the  operation. 

1  Decomposition  of  the  body  took  place  very  rapidly.  There 
was  a  good  deal  of  fetid  serum  in  the  peritoneal  cavity,  and 
some  traces  of  recent  peritonitis  were  also  shown  by  flakes  of 
lymph.  There  was  no  blood  or  clot  to  be  seen,  and  only  one 
or  two  shreds  of  sloughy  tissue  at  the  spot  where  the  tumour 
had  been  removed  from  the  right  side  of  the  uterus.  The 
peduncle  of  the  tumour  first  removed  connected  the  left  side  of 
the  uterus  closely  with  the  abdominal  wall.  The  adhering 
portion  of  intestine  observed  during  my  operation  was  so  closely 
attached  to  the  abdominal  wall  that  it  was  difficult  to  separate 
it  by  dissection;  and  the  greater  part  of  the  omentum  also 
adhered  to  the  abdominal  wall. 

'  This  case  alone  is  sufficient  to  prove  that  ovariotomy  may 
be  performed  twice  on  the  same  patient  without  any  unusual 
difficulty.  What  the  risk  may  be  as  compared  with  the  risk 
of  first  operations  can  only  be  ascertained  by  a  number  of 
cases. 

'  Eefiection  upon  this  case  would  seem  to  suggest  that,  in 
performing  the  operation  for  the  second  time  on  the  same 
patient,  it  may  prove  advisable  to  make  the  incision  at  some 
distance  from  the  cicatrix  left  after  the  first  operation ;  or,  if 
the  incision  be  made  near  the  cicatrix,  it  may  be  necessary  to 
leave  the  sutures  longer  than  in  ordinary  cases,  as  the  process 
of  union  may  be  slower  near  a  cicatrix  than  in  an  uninjured 
part. 


398  MY   FIRST   CASE    OF   OVARIOTOMY   DONE   TWICE 

'  The  lessons  suggested  to  those  who  perform  ovariotomy, 
under  ordinary  circumstances  are — 

*  1.  That  the  operator  should  be  careful  not  only  to  remove 
every  portion  of  an  ovarian  tumour  on  one  side,  if  it  be  possible 
to  do  so,  but  also  to  examine  the  opposite  ovary  carefully,  and 
to  be  guided  in  his  practice  by  the  knowledge  that  if  the  ovary 
be  not  healthy  and  be  left  behind,  morbid  growth  will  probably 
take  place,  and  a  second  operation  be  required. 

'  2.  That  in  uniting  the  wound  in  the  abdominal  wall  the 
divided  edges  of  peritoneum  should  be  brought  closely  together 
in  the  manner  which  I  was  the  first  to  propose  in  a  paper  pre- 
sented to  this  Society  five  years  ago.' 

Then  follow  remarks,  which  are  amplified  in  other  chap- 
ters of  this  volume,  supporting  this  conclusion.  But  it  now 
seems  clear  to  me  that  removal  of  the  clamp  and  of  the 
sutures  too  soon  was  the  chief  error  in  the  after-treatment 
of  this  patient,  and  it  is  very  probable  that  if  they  had 
been  left  longer  undisturbed,  the  case  would  have  ended  in 
recovery. 

The  case  which  I  am  now  about  to  condense  from  the 
fiftieth  volume  of  the  '  Medico-Chirurgical  Transactions '  is 
the  first  in  which  ovariotomy  was  twice  successfully  performed 
upon  the  same  patient  by  the  same  surgeon. 

'  I  performed  the  first  operation  in  the  Samaritan  Hospital 
on  February  15,  1865.  The  patient  was  an  unmarried  school- 
mistress, aged  twenty-four,  who  was  admitted  on  December  29, 
1864.  She  was  feeble,  and  had  a  strumous  appearance,  with  a 
hectic  flush  on  each  cheek.  The  whole  abdomen  wa*s  occupied 
by  an  irregular  tumour,  in  some  parts  of  which  fluctuation  was 
perceptible. 

'  The  parents  were  healthy ;  but  three  of  her  sisters  had 
died  of  phthisis.  She  herself  had  always  enjoyed  good  health, 
and  had  menstruated  regularly  up  to  Christmas  1863.  About 
that  time  her  body  began  to  enlarge  without  any  known  cause ; 
pain  in  the  left  side  became  tolerably  constant,  and  occasionally 
acute.  By  March  1864  the  swelling  was  chiefly  felt  on  the 
right  side  of  the  abdomen  ;  it  steadily  increased  in  size  and 
became  fluctuant.  In  October  1864  and  again  in  November  of 
the  same  year,  Dr.  Eobbs,  of  Grantham,  tapped,  and  on  each 
occasion  drew  off  about  twelve  pints  of  clear  viscid  fluid.     After 


SUCCESSFULLY  ON  THE  SAME  PATIENT         399 

her  admission  to  the  hospital  in  December,  a  little  swelling  of 
the  left  leg  was  observed.  On  January  4,  1865,  I  tapped  and 
removed  seventeen  pints  of  fluid.  After  the  tapping,  crural 
phlebitis  in  the  left  side  increased,  and  the  leg  and  thigh  were 
much  swollen  and  very  painful.  The  heart  and  liver  descended 
a  little,  and  the  general  health  improved ;  but  the  cyst  refilled 
rapidly,  and  on  January  30  I  tapped  again  and  removed  eigh- 
teen pints  of  whitish  glutinous  fluid,  similar  to  that  before 
evacuated.  After  this  tapping,  groups  of  cysts,  irregularly 
disposed,  and  evidently  adhering  in  some  places  to  the  abdo- 
minal wall,  were  felt  filling  the  whole  of  the  hypogastric  region, 
and  on  the  right  of  the  median  line,  above  the  umbilicus, 
extending  nearly  up  to  the  sternum. 

'  Although  the  feeble  state  of  the  general  health,  the  dis- 
placement of  the  thoracic  viscera,  and  the  family  history,  did 
not  augur  favourably  for  ovariotomy,  it  was  so  clearly  the  only 
resource  that  it  was  performed  on  February  15,  after  consulta- 
tion with  Dr.  Routh.  An  incision  was  commenced  one  inch 
below  the  umbilicus,  and  carried  downwards  for  five  inches  ; 
there  were  extensive  adhesions  between  the  cyst  and  abdominal 
wall,  above  and  to  the  right  of  the  incision,  extending  to  the 
brim  of  the  pelvis,  but  they  gave  way  to  the  hand.  Having 
tapped  and  emptied  a  large  cyst,  and  broken  down  a  second 
within  the  first,  the  tumour  was  drawn  out,  and  a  piece  of 
adhering  omentum  was  separated.  The  pedicle  was  three  to 
four  inches  in  length,  extending  from  the  left  side  of  a  long 
thin  uterus ;  it  was  secured  in  a  small  clamp,  and  left  outside 
without  traction.  There  was  a  little  oozing  from  the  separated 
adhesions.  The  blood  was  carefully  sponged  away,  but  no 
vessel  required  ligature.  The  right  ovary  was  felt  to  be 
healthy.  The  wound  was  closed  with  five  deep  and  three 
superficial  sutures. 

*  The  patient  rallied  well,  complained  of  but  little  pain,  and 
only  required  one  opiate.  The  stitches  were  all  removed  on 
the  third  day — the  clamp  on  the  eighth  day.  The  bowels 
acted  for  the  first  time  on  the  thirteenth  day,  but  there  had 
been  no  uneasiness  from  the  prolonged  constipation.  She  left 
the  hospital  four  weeks  after  the  operation,  and  returned  to  the 
country  in  good  health. 

'  About  twenty-two  pints  of  fluid  were  evacuated  at  the 


400  STATE   OF   PATIENT   BEFORE   SECOND    OPERATION 

operation,  and  the  more  solid  remainder  of  the  tumour  weighed 
about  seven  pounds. 

'  The  patient  remained  well  for  more  than  a  year  after  the 
first  operation.  On  February  14  last  she  wrote  to  me  as 
follows :  "  A  year  having  elapsed  since  my  operation,  I  am 
thankful  to  tell  you  that  I  am  quite  strong  again,  and  have 
never  taken  any  medicine  since  I  left  the  hospital.  I  am  a 
wonder  to  myself  when  I  consider  how  dangerously  ill  I  was." 
I  did  not  hear  of  her  after  this  until  she  came  to  town  and 
called  on  me,  on  August  6,  when  I  found  a  semi-solid  tumour 
of  the  right  ovary,  reaching  up  to  the  false  ribs  on  the  right 
side,  in  the  centre  to  two  inches  above  the  umbilicus,  and 
extending  towards  the  left  side  half  way  between  the  umbilicus 
and  anterior  superior  spine  of  the  ilium.  The  uterus  was 
freely  movable.  She  said  she  had  not  noticed  any  increase  in 
size  for  more  than  a  month,  but  had  felt  pain  in  the  right  side 
in  the  spring.  The  catamenia  had  been  regular  till  a  month 
ago,  but  latterly  had  become  scanty.  At  the  periods  in  April 
and  May  dysmenorrhoeal  pain  was  excessive.  There  was  some 
cough,  but  no  very  urgent  symptom,  and  she  returned  to  the 
country  to  consider  my  advice  to  submit  again  to  ovariotomy 
before  her  general  health  became  seriously  impaired.  About 
a  fortnight  later,  on  August  24,  her  sister  wrote  to  tell  me  that 
the  patient's  cough  had  become  very  troublesome,  and  she  was 
so  much  weaker,  and  generally  so  much  worse,  that  if  she 
continued  to  lose  her  strength  she  would  not  be  able  to  go 
through  the  operation.  As  the  Samaritan  Hospital  was  closed 
for  repairs,  a  room  in  the  neighbourhood  was  procured,  and  the 
patient  came  to  town  on  August  29.  The  tumour  had  grown 
very  rapidly,  dyspnoea  and  cough  were  very  troublesome,  tem- 
perature in  axillae  101°  Fahr.,  and  urine  scanty.  She  had 
begun  to  perspire  a  great  deal  at  night.  The  catamenia  were 
expected  in  ten  days.  Careful  examination  of  the  chest  failed 
to  detect  anything  not  explicable  by  the  displacement  upwards 
of  the  diaphragm  by  the  ovarian  tumour,  which  just  reached 
the  ensiform  cartilage.  As  there  was  no  cyst  large  enough  to 
tap  with  any  hope  of  affording  even  temporary  relief,  I  per- 
formed ovariotomy  the  day  after  she  arrived  in  town,  August 
30,  1866,  just  eighteen  months  and  a  half  after  the  first  opera- 
tion.   Professor  White,  of  Buffalo,  United  States,  and  Dr.  Hjort, 


ACCOUNT  OF  SECOND  OPERATION  401 

of  Christiania,  were  present.  I  was  assisted  by  Dr.  Bowen  and 
Dr.  Wright,  and  Dr.  Junker  administered  chloroform.  Bearing 
in  mind  the  slow  and  imperfect  union  in  my  former  second 
operation,  when  I  made  the  incision  very  near  the  cicatrix  of 
the  first  operation,  I  made  it  in  this  case  an  inch  and  a  half  to 
the  right  of  the  cicatrix  (which  was  exactly  in  the  middle 
line),  and  carried  it  from  one  inch  above  the  umbilical  level 
downwards  for  five  inches.  Its  lowest  point  was  about  half  an 
inch  higher  than  the  level  of  the  lowest  point  of  the  cicatrix. 
Three  arteries,  one  of  considerable  size,  were  divided  near  the 
lower  end  of  the  incision,  beneath  the  divided  muscle,  and 
were  tied  before  the  peritoneum  was  opened.  A  thin-walled 
compound  cyst  was  closely  adherent  all  over  its  anterior  surface, 
but  the  adhesions  yielded  easily  to  my  hand.  I  introduced  a 
large  trocar,  but  the  cysts  were  too  small  and  the  contents 
too  viscid  for  any  fluid  to  escape.  I  accordingly  opened  the 
tumour,  broke  it  up  inside,  pressed  out  a  great  deal  of  its  viscid 
contents,  and  then  withdrew  the  remainder,  after  separating  a 
piece  of  adhering  omentum.  A  broad  thin  pedicle  extended 
about  two  inches  from  the  right  side  of  the  uterus.  The 
uterus  was  in  its  normal  position ;  but  the  pedicle  of  the 
tumour  removed  at  the  first  operation  passed  from  the  left  side 
of  the  uterus  and  adhered  firmly  to  the  lower  angle  of  the 
cicatrix  in  the  middle  line  of  the  abdominal  wall.  The  pedicle 
of  the  tumour  about  to  be  removed  was  enclosed  in  a  broad 
clamp,  and  the  tumour  was  cut  away ;  three  omental  vessels 
were  tied,  and  the  ligatures  cut  off  short.  There  was  very  little 
bleeding,  but  as  some  ovarian  fluid  had  escaped,. the  peritoneal 
cavity  was  carefully  sponged  out.  The  pedicle  on  the  left  side 
interfered  a  little  with  this  process,  but  it  was  continued  until 
the  sponges  came  quite  clean  from  the  lowest  part  of  the  space 
between  the  uterus  and  rectum.  Finding  that  there  would  be 
considerable  traction  on  the  uterus  and  broad  ligament  if  the 
clamp  were  kept  outside,  I  determined  to  apply  the  actual 
cautery  and  burn  off  the  portion  of  cyst  left  above  the  clamp, 
and  be  prepared  to  tie  any  vessel  which  might  bleed  on 
removing  the  clamp.  Protecting  the  abdominal  wall  by  two 
shields  of  talc — a  most  perfect  non-conductor  of  heat — I  used 
three  or  four  hot  irons,  and  as  on  separating  the  blades  of  the 
clamp   there   was   no   bleeding,   the   compressed    and   seared 

D  D 


402  DESCRIPTION   OF  TUMOUR 

pedicle  was  allowed  to  sink  into  the  pelvis.  The  wound  was 
closed  by  silk  sutures.  The  fluid  or  jelly-like  substance  re- 
moved with  the  fragments  of  the  broken-up  tumour,  together 
measured  eighteen  pints.  The  following  description  of  the 
tumour  is  by  Dr.  Junker  : — 

' "  The  tumour  consisted  of  an  oblong  mass,  divided  by 
delicate  fibro-membranous  septa  into  numerous  chambers  or 
loculi  of  various  size.  These  septa,  as  well  as  the  main  wall, 
were  exceedingly  thin  and  friable  ;  so  much  so  that  the  tumour 
broke  up  into  fragments  on  very  slight  pressure.  Some  por- 
tions of  the  main  wall  and  of  the  septa  were  very  vascular,  and 
covered  with  what  appeared  to  the  naked  eye  circumscribed 
round  or  oval  red  spots,  having  diameters  varying  from  one  to 
three  lines.  Under  the  microscope,  however,  these  spots  proved 
to  be  a  dense  capillary  network,  with  well-defined  abruptly 
terminating  outlines.  The  interior  of  the  loculi  was  in  many 
places  coated  by  a  true  tubercular  deposit,  often  corresponding 
in  size  and  situation  to  the  red  spots  just  described.  In  other 
places  the  tubercular  exudation  was  more  profuse,  and  some  of 
the  lesser  loculi  were  entirely  filled  by  yellow  tubercular 
masses.  Genuine  tubercles,  softening,  or  in  a  state  of  creti- 
fication  (Verkreidung,  of  Eokitansky),  were  also  found  im- 
bedded in  the  stroma.  In  some  places  the  septa  were  softened 
or  destroyed  by  the  tubercles.  The  loculi  were  filled  with  a 
thin  reddish  or  yellow,  slightly  ropy  fluid,  which  in  some  of 
the  chambers  appeared  more  turbid  from  the  presence  of 
minute  tubercles  suspended  in  the  fluid." 

4  The  progress  of  the  patient  after  the  second  operation  was 
quite  as  satisfactory  as  after  the  first.  There  was  rather  more 
pain  and  sickness  during  the  first  thirty-six  hours  after  opera- 
tion, and  three  opiates  were  required  during  the  first  twelve 
hours.  After  the  second  day  all  unfavourable  symptoms  ceased, 
and  she  made  a  most  satisfactory  recovery,  returning  to  Lin- 
colnshire twenty-nine  days  after  the  operation.' 

'Note  added  November  13,  1866. — I  have  heard  from  her 
twice  since  her  return  home.  The  last  letter  is  dated  November 
10,  1866.  She  says,  "I  think  upon  the  whole  I  feel  as  well  as 
I  did  after  my  first  operation.  My  voice  is  stronger.  I  can 
sing  the  upper  notes  with  greater  facility  than  formerly.  I  can 
sing  from  A  up  to  C  natural."     I  was  curious  to  have  the  range 


SECOND  SUCCESSFUL  CASE  403 

and  power  of  the  voice  observed  after  the  removal  of  both 
ovaries,  and  it  could  be  done  with  unusual  accuracy  in  this 
case,  as  the  patient  is  a  teacher  of  singing.' 

In  1867  this  patient  went  to  reside  at  Brighton,  and  fulfilled 
her  duties  as  a  schoolmistress  there  for  more  than  a  year.  I 
heard  of  her  more  than  once  as  being  in  good  health,  but  on 
June  30,  1868,  I  received  a  letter  from  Mr.  Humphry,  stating 
that  she  had  died  two  days  before,  and  adding,  '  About  a  week 
before  her  death  I  saw  her  for  the  first  time,  when  she  had 
slight  congestion  at  the  bottom  of  one  lung.  In  two  or  three 
days  this  subsided,  but  she  seemed  to  get  worse,  great  prostra- 
tion, some  sickness,  small,  quick  pulse,  restlessness  of  manner, 
and  some  fulness  of  abdomen  leading  me  to  fear  some  serious 
mischief  about  the  seat  of  the  old  disease.  These  increased, 
with  swelling  of  the  left  leg,  which  was  painless,  as  was  the 
abdomen ;  and  she  quickly  sank.  I  found  about  a  gallon  of 
almost  clear  serum  in  the  abdomen.  No  general  adhesions. 
One  pedicle  adherent  to  lower  end  of  scar  in  the  abdominal 
wall,  and  adhesion  between  bowel  and  bladder.  Uterus  very 
small  and  elongated,  from  dragging  to  abdominal  wall  through 
pedicle.  Clot  in  left  iliac  vein.  No  other  sign  of  disease.  I 
could  only  lay  the  attack  to  cold.' 

In  the  next  case  where  I  performed  ovariotomy  successfully 
twice  on  the  same  patient,  the  first  operation  was  performed 
in  December  1861.  It  was  my  thirtieth  case  of  ovariotomy, 
and  I  quote  from  the  report  published  in  1865,  specially 
directing  attention  to  the  examination  of  the  opposite  ovary, 
and  the  laying  open  of  a  cyst  of  the  broad  ligature  at  the 
time  : — 

'  A.  H.,  a  cook,  single,  50  years  of  age,  was  admitted  on 
December  14, 1861,  under  my  care,  into  the  Samaritan  Hospital, 
having  been  sent  to  me  by  Mr.  Miles,  of  Gillingham.  She  has 
been  tapped  twelve  times,  the  quantity  increasing  and  the  fluid 
becoming  thicker  every  time.  The  last  tapping  was  eight 
weeks  ago,  when  thirty  pints  of  fluid  were  removed  in  a  private 
hospital  where  she  was  told  that  her  case  was  too  unfavourable 
for  ovariotomy. 

'  Considering  that  a  menstrual  period  had  ceased  a  week 
before  her  admission,  that  her  size  rendered  immediate  relief 
necessary,  that  each  tapping  would  lessen  the  probability  of 

l>    D   2 


404  FIRST   OPERATION 

success  after  ovariotomy,  and  that  she  was  very  anxious  to  have 
the  operation  performed,  it  was  decided  to  operate  without  delay. 

'  The  operation  was  performed  on  December  17,  1861 ;  Dr. 
Parson  administered  chloroform.  Dr.  Marion  Sims,  of  New 
York,  Mr.  Miles,  jun.,  of  Grillingham,  and  several  other  gentle- 
men were  present.  An  incision  was  made  five  inches  long  over 
the  linea  alba,  midway  between  the  umbilicus  and  symphysis 
pubis,  going  through  some  of  the  cicatrices  left  by  tappings. 
The  principal  cyst  was  so  closely  adherent  here  that  careful 
dissection  was  necessary  to  separate  it  from  the  peritoneum, 
and  the  cyst  was  opened  during  the  process  and  emptied.  More 
extensive  parietal  adhesions  were  then  separated  by  the  hand, 
and  some  groups  of  smaller  cysts  emptied  by  breaking  them 
down  with  one  hand  in  the  empty  cyst,  while  the  other  hand 
was  occupied  in  gradually  withdrawing  the  mass  of  emptied 
and  broken-down  cysts.  The  pedicle  was  short,  but  was  easily 
secured  by  a  clamp  about  an  inch  from  the  right  side  of  the 
uterus,  and  the  tumour  was  then  cut  away.  On  examining  the 
left  ovary,  it  was  found  atrophied,  but  a  thin-walled  single  cyst, 
as  large  as  an  orange,  was  observed  close  to  the  uterus,  within 
the  folds  of  the  left  broad  ligament.  This  was  laid  open  by  an 
incision  and  emptied.  The  wound  was  then  closed  by  silver 
sutures,  carried  through  the  whole  thickness  of  the  abdominal 
wall,  including  the  peritoneum.  The  clamp  had  been  left  on, 
and  it  was  secured  with  the  stump  of  the  pedicle  at  the  lower 
angle  of  the  wound.  The  cyst  walls  and  groups  of  small  cysts 
removed  weighed  between  nine  and  ten  pounds ;  and  they  had 
contained  about  thirty  pints  of  fluid,  so  that  the  entire  weight 
of  the  tumour  was  nearly  forty  pounds. 

*  The  progress  after  the  operation  was  most  satisfactory. 
The  patient  had  so  little  pain  that  not  even  a  single  dose  of 
opium  or  of  any  other  medicine  was  either  given  or  required. 
The  pulse  never  rose  above  96,  and  was  generally  about  80. 
The  clamp  was  removed  on  the  fifth  day,  the  slough  then  being 
quite  dry  and  hard.  The  sutures  were  removed  on  the  seventh 
day,  when  the  wound  was  found  to  be  firmly  closed.  The 
bowels  acted  on  the  ninth  clay,  and  on  December  31  the  patient 
was  eating  and  sleeping  well,  and  thoroughly  convalescent. 
She  left  the  hospital  in  good  health,  and  afterwards  worked 
well  as  cook  in  a  large  family. 


CONDITION  AFTERWARDS  405 

c  This  case  shows  that  even  in  late  stages  of  ovarian  disease, 
in  a  patient  past  middle-age,  and  after  repeated  tappings,  ova- 
riotomy may  be  performed  with  success.  The  chief  peculiarity 
in  this  case  was  the  small  cyst  found  in  the  opposite  broad 
ligament,  after  removal  of  one  ovarian  tumour.  The  cyst  was 
so  closely  adherent  to  the  uterus  that  it  could  not  have  been 
removed  with  safety ;  and  as  it  is  well  known  that  thin-walled 
single  cysts  in  this  situation  seldom  refill  after  they  have  been 
emptied,  I  thought  it  not  probable  that,  as  it  was  freely  laid 
open,  it  could  lead  to  future  trouble.'  And  for  more  than  five 
years  the  result  was  very  satisfactory.  But  in  November  1867, 
Mr.  Miles  again  wrote  to  me,  stating  that  the  patient  upon 
whom  I  had  operated  six  years  before  had  lately  returned  from 
service  with  signs  of  a  recurrence  of  the  disease,  having  a  cyst 
in  the  abdomen  of  about  the  size  and  shape  of  the  womb  at  the 
sixth  or  seventh  month  of  pregnancy.  She  was  admitted  into 
the  Samaritan  Hospital,  November  15,  1867,  giving  her  age  as 
fifty-six.  She  said  she  had  menstruated  regularly  up  to  the 
time  of  the  first  ovariotomy,  and  once  a  fortnight  afterwards. 
It  then  ceased  for  a  year ;  then  she  had  a  persistent  discharge 
for  a  few  weeks,  and  it  then  ceased  altogether.  She  had  felt 
perfectly  well,  and  had  acted  as  a  cook  until  May  1867,  when 
abdominal  pain  came  on,  followed  by  enlargement  which 
gradually  increased.  The  greater  part  of  the  abdomen  was 
occupied  by  a  fluctuating  cyst,  the  abdomen  being  very  hard 
and  tender  in  the  left  iliac  fossa.  The  cervix  uteri,  with  its 
canal,  was  opened  and  dilated  by  a  mucous  polypus.  This  I 
drew  down,  and  divided  a  small  pedicle  with  scissors.  The 
polypus  was  as  large  as  a  walnut.  Bleeding  was  so  free  that  it 
was  necessary  to  plug  the  vagina.  A  fortnight  afterwards,  I 
tapped  midway  between  the  umbilicus  and  the  right  ilium, 
and  drew  off  seven  pints  of  viscid  ovarian  fluid.  She  was 
relieved  by  this,  and  went  to  the  Convalescent  Hospital 
December  13,  1867.  She  was  readmitted  January  25,  1868. 
The  cyst  was  then  well  defined,  extending  on  the  left  side  from 
the  iliac  region  to  the  false  ribs,  on  the  right  side,  about  half- 
way from  the  umbilicus  to  the  spine  of  the  ilium,  and  above, 
half-way  between  the  umbilicus  and  the  sternum.  The  cer- 
vix uteri  was  high  up,  and  there  wa3  some  offensive  discharge 
from  the  vagina.     Injections  were  used  daily.     The  vaginal  d is- 


406  SECOND   OPERATION 

charge  ceased,  and  the  cyst  being  fully  as  large  or  larger  than 
before  tapping,  I  performed  the  second  ovariotomy  on  February 
5,  1868.  Chloromethyl  was  given  by  Dr.  Junker.  I  made  the 
incision  parallel  with  the  cicatrix  over  the  linea  alba,  but  an 
inch  and  a  half  to  the  left  of  it,  and  extending  about  an 
inch  lower.  Two  vessels  were  tied  before  the  peritoneum  was 
opened.  The  cyst  was  exposed  and  tapped.  The  only  adhesions 
were  to  a  piece  of  omentum,  which  also  adhered  to  the  abdominal 
wall  beneath  the  cicatrix  and  to  a  coil  of  intestine.  These  ad- 
hesions were  easily  separated.  On  withdrawing  the  empty  cyst 
and  a  group  of  secondary  cysts,  the  uterus  was  seen  to  be  held 
up  near  the  lower  end  of  the  cicatrix  by  the  pedicle  of  the 
tumour  removed  in  1861.  The  cyst  on  the  left  side  had  a  broad 
attachment  behind  and  to  the  left  of  the  uterus.  There  was  not 
room  to  apply  a  cautery  clamp  without  injury  to  the  uterus, 
and  I  accordingly  cut  away  the  base  of  the  cyst,  tying  all 
vessels  which  bled  as  I  went  on,  separating  the  extremity  of  the 
Fallopian  tube  from  the  part  of  the  cyst  to  which  it  adhered, 
and  leaving  a  small  portion  of  cyst  wall  closely  adhering  to  the 
inner  part  of  the  tube  and  to  the  uterus.  Very  little  blood  was 
lost,  but  there  were  two  ligatures  on  vessels  in  the  abdominal 
wall,  three  on  omental  vessels,  five  or  six  on  vessels  in  the 
cyst  wall,  and  one  on  the  separated  end  of  the  Fallopian  tube 
and  cyst. 

The  cyst  weighed  fifteen  ounces  and  contained  seven  pints  of 
fluid.  It  was  a  multilocular  proliferous  cyst  with  very  vascular 
walls,  the  arteries  being  small,  but  numerous  and  tortuous, 
and  many  of  the  veins  as  large  as  a  crow  quill.  She  went  on 
well,  although  nervous,  feverish,  and  subject  to  palpitation, 
afterwards  explained  by  the  discovery  that  she  had  a  large 
secret  supply  of  brandy.  Yet  she  left  for  Gillingham  twenty- 
eight  days  after  operation,  on  March  5,  1868.  On  March  16, 
Mr.  Miles  wrote,  '  Her  appetite  is  good,  pulse  quiet,  no  wound, 
no  abdominal  tenderness.  It  is  a  remarkably  successful  case.' 
Two  months  afterwards — May  22,  1868 — he  wrote:  'About 
three  weeks  ago  I  found  that  she  insisted  upon  keeping  her 
bed,  although  her  tongue  was  clean,  appetite  good,  pulse  quiet 
and  firm,  and  she  had  gained  flesh.  I  thereupon,  after  very 
great  obstinacy,  got  her  to  put  on  her  clothes,  and  then  in  a 
few  days  to  get  downstairs  and  go  out  in  a  Bath  chair,  and  she 


FOURTH   CASE  407 

bears  it  all  well,  though  not  with  a  good  grace  ;  but  I  wish  to 
ask  if  you  can  account  for  the  great  craving  for  food  which 
she  has  ?  She  is  most  irritable  if  it  is  not  brought  the  moment 
it  is  ordered  by  night  and  day.  She  makes  a  good  deal  of  pale 
urine;  sp.  gr.  1015,  contains  no  sugar.'  In  reply  I  alluded  to 
the  amount  of  brandy  she  drank  without  my  knowledge  whilst 
in  the  hospital.  And  I  heard  again  from  Mr.  Miles  that  '  she 
died  on  October  6,  1868,'  just  eight  months  after  the  second 
operation.  Mr.  Miles  did  not  make  any  post-mortem  examina- 
tion, and  registered  the  cause  of  death  as  '  aberration  of 
mind  and  voluntary  abstinence  from  food.'  He  afterwards 
informed  me  that  she  became  quite  fleshy,  and  able  to  walk 
three  or  four  miles,  until  she  began  obstinately  to  refuse  all 
food. 

In  one  other  case  I  went  prepared  to  perform  ovariotomy 
upon  a  lady  whose  right  ovary  I  had  previously  removed  suc- 
cessfully ;  but  I  found  the  uterus  and  left  ovary  quite  healthy, 
and  a  very  thin-walled  cyst  attached  only  to  the  abdominal 
wall,  as  if  it  had  arisen  at  a  spot  where  some  firm  adhesions  had 
been  separated  at  the  first  operation.  I  emptied  the  cyst,  laid 
it  freely  open,  and  saw  the  patient  several  years  afterwards  in 
good  health. 

I  reprint  from  my  volume  of  cases  published  in  1865,  and 
entitled  'Diseases  of  the  Ovaries,'  p.  112,  the  account  of  the 
first  operation  in  the  next  case,  where  it  was  performed  twice 
on  the  same  patient : — 

'  An  unmarried  lady,  28  years  of  age,  was  sent  to  me  by 
Dr.  West  on  June  7,  1862.  With  the  exception  of  monor- 
rhagia, which  had  always  been  troublesome,  she  had  been  well 
until  the  preceding  summer.  She  then  had  some  pain  low 
down  on  the  left  side,  but  it  went  away,  and  recurred  more 
violently  in  November  1861.  Pain  and  sickness  became  fre- 
quently troublesome,  and  were  increased  at  the  periods.  In 
January  1862  Dr.  West  was  consulted,  and  detected  ovarian 
disease.  The  size  continued  to  increase ;  and,  in  March,  Sir 
J.  Paget  removed  six  quarts  of  fluid  by  tapping,  and  injected 
iodine.  Sickness  and  pain  were  severe  for  three  days.  She 
remained  small  for  a  month  or  six  weeks,  but  had  increased  to 
about  the  same  size  as  before  the  tapping.  The  girth  was  thirty <- 
seven  inches,  length  from  sternum  to  pubes  fifteen  inches.     The 


408  FIRST   OPERATION   WITH   THE   tiCRASEUR 

whole  abdomen  was  filled  by  a  non-adherent  cyst,  which  ap- 
peared to  be  unilocular,  or  nearly  so,  from  the  extreme  regularity 
of  the  fluctuation  in  all  directions.  It  was  found  afterwards 
that  this  was  owing  to  the  tension  of  small  cysts  with  very  thin 
cyst-walls.  The  pelvis  was  free,  but  the  uterus  was  elevated, 
drawing  up  the  vagina  like  a  long  funnel. 

'  I  advised  ovariotomy  without  delay,  and  performed  the 
operation  on  June  11,  1862.  Dr.  Parson  gave  chloroform; 
Mr.  Bateman,  of  Islington,  Mr.  Pierce,  of  Notting  Hill,  and 
Dr.  Savage  were  present.  On  opening  the  peritoneum  by  an 
incision  between  four  and  five  inches  long,  extending  downwards 
from  an  inch  below  the  umbilicus,  some  small  tense  cysts  with 
very  thin  walls  were  seen,  emptied,  and  withdrawn.  Some 
adhesions  near  the  site  of  the  tapping  were  then  separated,  and 
the  whole  tumour  brought  out.  I  then  found  that  the  tumour 
was  quite  closely  attached  to  the  right  side  of  the  uterus ;  there 
was  nothing  like  a  pedicle.  I  accordingly  passed  the  chain  of 
an  ecraseur  above  the  Fallopian  tube  and  below  the  round  liga- 
ment, and  tightened  it  quite  close  to  the  uterus.  I  then  cut 
away  the  tumour,  and  afterwards  pared  down  the  stump  nearly 
to  the  tight  chain.  I  then  loosened  the  chain,  intending  to 
tie  any  vessels  which  bled,  but  there  was  no  bleeding.  So  the 
chain  was  removed,  the  pelvis  cleansed,  the  left  ovary  found  to 
be  healthy,  two  small  pedunculated  cysts  of  the  left  broad  liga- 
ment twisted  off,  and  the  wound  was  closed  by  two  deep  and 
four  superficial  sutures  of  platinum  wire. 

'  There  was  no  sign  of  hemorrhage  after  the  operation,  but 
more  opium  than  usual  was  taken  on  account  of  pain.  Sickness 
also  was  troublesome  on  the  second  day.  There  was  a  little 
oozing  of  blood  from  one  of  the  stitches  at  night  and  next 
morning,  but  it  ceased  spontaneously.  Early  on  the  third  day 
the  catamenia  appeared  and  continued  freely.  After  this  she 
improved.  On  the  sixth  day  I  removed  the  deep  sutures.  A 
little  pus  came  from  the  track  of  each.  Two  days  afterwards 
she  was  restless,  and  bilious  vomiting  recurred.  I  removed  the 
superficial  sutures,  a  drop  or  two  of  pus  following  each,  and  a 
small  slough  was  caused  by  the  lowest;  but  the  wound  was 
quite  healed.  For  the  next  three  days  she  was  restless,  and 
there  was  free  oozing  of  pus  from  two  of  the  suture  points ;  but 
she  went  out  of  town  on  June  30,  with  the  wound  quite  healed, 


HISTORY   AFTER   FIRST   OPERATION  409 

soon  gained  strength,  was  married  in  the  summer  of  1863,  and 
a  fine  strong  child  was  born  in  August  1864.  Dr.  King,  of 
Camberwell,  attended  her,  and  informed  me  that  the  labour 
was  perfectly  natural. 

'  I  used  platinum  sutures  in  this  case,  to  ascertain  if  any 
advantage  would  arise  from  the  use  of  a  metal  which  would  not 
oxidize  like  silver  or  iron,  and  remembering  the  use  of  platinum 
sutures  twenty-five  years  ago  by  Mr.  Morgan  at  Gruy's  Hospital. 
But  I  have  scarcely  ever  seen  so  much  suppuration  in  the  track 
of  the  sutures  as  in  this  case ;  and  it  taught  me  to  look  to  the 
size  of  the  needle,  the  size  and  smoothness  of  the  thread  or 
silk,  the  tightness  with  which  it  is  tied,  and  the  time  it  is  left, 
as  having  more  to  do  with  suppuration  or  sloughing  than  the 
material  of  which  the  suture  is  composed.' 

Continuing  the  history  of  this  case  after  the  marriage  in 
1863,  and  birth  of  the  first  child  in  1864,  I  have  to  add  that 
a  second  child  was  born  in  February  1866,  and  the  patient 
again  became  pregnant  early  in  1867.  Up  till  this  time  the 
health  had  been  very  good,  but  then  disease  reappeared,  so 
that  she  required  tapping  during  the  pregnancy.  Another 
tapping  followed,  and  in  May  1868  her  medical  attendant,  Mr. 
Griffith,  wrote  that  '  she  had  no  bad  symptom  after  the  tapping. 
The  vomiting  has  ceased,  and  with  the  diminished  abdominal 
tension  I  can  feel  what  appears  to  be  almost  a  solid  substance 
of  considerable  size  on  the  left  side,  similar  to  but  larger  than 
what  I  felt  after  the  last  tapping.'  Towards  the  latter  end  of 
May  the  distension  again  rapidly  advanced,  the  measurement 
at  the  waist  increasing  at  the  rate  of  three  inches  in  ten  days ; 
but  the  general  health  continued  good.  She  was  again  tapped 
in  June  1869,  and  the  second  operation,  for  removal  of  the 
second  tumour,  was  undertaken  on  the  21st  of  the  same  month. 

The  incision  was  made  parallel  to,  and  half  an  inch  to  the 
left  of,  the  cicatrix  of  the  first  operation,  extending  from  the 
umbilicus  to  a  point  two  inches  above  the  pubes.  A  little 
ascitic  fluid  escaped  on  opening  the  peritoneum,  and  a  coil  of 
intestine  was  seen,  as  well  as  a  large  piece  of  omentum,  which 
adhered  to  the  abdominal  wall  around  the  umbilical  ring.  On 
introducing  the  hand,  and  pressing  the  intestine  and  omentum 
upward,  I  brought  a  tumour  forward  and  tapped  a  very  thin 
transparent  cyst.     Two  or  three  pints  of  clear  serum  escaped, 


410  SECOND    OPERATION 

and  I  then  found  a  solid  fibroid  tumour  to  be  closely  attached 
to  the  upper  and  back  part  of  the  uterus.  A  coil  of  intestine 
and  a  piece  of  omentum  which  adhered  to  the  tumour  were 
separated  from  it,  and  the  tumour  was  drawn  outward.  The 
chain  of  an  ecraseur  was  then  passed  behind  the  uterus  around 
the  neck  of  the  tumour,  avoiding  the  right  ovary  and  right 
Fallopian  tube,  which  were  healthy.  The  chain  was  slowly 
tightened,  and  the  tumour  pared  away  near  the  chain.  One 
omental  vessel  was  tied,  and  the  ligature  returned  with  the 
omentum.  Some  stitches  were  then  inserted  to  close  the  upper 
part  of  the  wound,  the  chain  of  the  ecraseur  being  occasionally 
tightened.  As  it  cut  through  there  was  free  bleeding,  and 
some  vessels  were  tied  on  the  posterior  surface  of  the  body  of 
the  uterus,  and  close  to  the  left  Fallopian  tube,  which  had 
been  divided. 

When  bleeding  appeared  to  have  ceased,  the  remaining 
sutures  were  applied  and  the  peritoneal  cavity  carefully  sponged. 
Some  oozing  of  blood  continuing,  the  uterus  was  again  exa- 
mined, and  perchloride  of  iron  was  applied  to  part  of  the 
surface  where  there  was  some  oozing.  At  length  the  wound 
was  closed,  the  sutures  being  passed  so  as  to  include  the  opening 
at  the  umbilical  ring,  and  two  others  beside  the  cicatrix,  where 
there  had  been  hernial  protrusion. 

The  patient  had  been  one  hour  and  five  minutes  from 
beginning  to  inhale  methylene  until  she  was  carried  to  bed. 
There  was  some  sickness  during  the  operation,  and  it  continued 
afterwards,  though  during  the  first  day  there  was  no  other  bad 
symptom.  She  soon,  however,  began  to  show  signs  of  failing 
power,  and  died  sixty-six  hours  after  the  operation. 

At  the  post-mortem  examination  five  or  six  ounces  of  bloody 
serum  were  found  in  the  peritoneal  cavity,  and  some  of  the 
small  intestines  were  slightly  adherent  from  recent  exudation 
of  fibrine.  The  uterus  and  other  parts  were  sent  to  Dr.  Wilson 
Fox  for  examination,  whose  report  runs  as  follows :  *  The 
tumour  is,  I  believe,  a  fibro-sarcoma,  with  a  large  proportion 
of  cells  like  organic  muscular  fibres,  but  others  are  mere  fibre 
cells.  Besides  these,  there  are  a  great  number  of  round  and 
oval-shaped  nuclei.  The  tumour  has  under  the  microscope 
a  minutely  lobed  character ;  i.e.  it  is  traversed  by  septa  in  all 
directions,  and  in  the  septa  the  muscular  fibres,  and  also  the 


DESCRIPTION    OF   THE   TUMOUR  411 

fibre  cells,  are  the  most  abundantly  accumulated.  The  section 
is  everywhere  opaque,  and  glistening  and  firm ;  a  few  striae  of 
fatty  degeneration  are  seen  in  spots  only.  Parts  of  the  tumour 
are  breaking  up  into  a  recticular  structure,  in  the  meshes  of 
which  a  clear  serous  fluid  is  contained.  Various  cysts,  from 
the  capacity  of  a  large  walnut  to  that  of  a  hazelnut,  are  also 
scattered  through  it,  in  addition  to  the  larger  ones  opened 
before.  As  to  whether  this  tumour  represents  a  sarcoma  of  the 
ovary,  I  am  not  prepared  to  pronounce  a  positive  opinion  ;  but 
in  some  parts  there  are  little  cavities  with  well-defined  walls, 
which  look  as  if  they  might  be  the  remains  of  the  Graafian 
follicles,  but  the  walls  are  completely  changed  by  the  fibro- 
plastic growth,  and  their  lining  does  not  show  any  remaining 
distinct  traces  of  the  membrana  granulosa.  They  appeared 
empty,  and  two  or  three  times  the  size  of  the  ordinary  Graafian 
follicles.  The  amount  of  muscular  tissue  present  is  not,  I 
think,  enough  to  invalidate  an  ovarian  origin.  The  general 
character  of  the  tumour  is  unlike  the  fibroids  of  the  uterus 
which  I  have  seen,  but  I  have  not  made  these  latter  the  objects 
of  a  sufficiently  comprehensive  study  to  be  able  to  speak 
positively  on  this  point.  If  the  tumour  is  ovarian,  as  I  am 
inclined  to  think,  there  would  appear  to  be  a  double  source  of 
cyst  formation  in  it — one,  the  liquefaction  or  breaking  down 
into  cavities,  such  as  is  seen  in  the  whole  class  of  these 
tumours ;  and  the  other,  from  enlarged  and  altered  Graafian 
follicles.' 

During  the  operation,  besides  the  tumour,  I  found  in  the 
abdominal  cavity  a  free,  spheroidal  body,  measuring  two  inches 
in  its  long  diameter,  and  an  inch  and  a  half  in  breadth,  and 
three-quarters  of  an  inch  in  thickness.  Its  weight  was  241 
grains.  It  was  semi-elastic,  of  dark  brownish-yellow  colour, 
and  the  surface  was  smooth  and  shining.  It  consisted  entirely 
of  fat  and  cholesterine  crystals,  and  had  an  exceedingly  delicate 
investment  of  connective  tissue,  with  fascicles  of  nucleated 
fusiform  cells  and  elastic  fibres.  This  body  was  evidently  one 
of  the  appendices  epiploic*,  which  had  separated  from  its 
pedicle,  and  had  remained  some  time  free  in  the  abdominal 
cavity. 

During  the  attendance  with  Dr.  Griffith,  in  1862,  doubt 
arose,  which  my  memory  did  not  enable  me  to  clear  up,  whether 


412  SIDE   OF   DISEASE 

I  had  been  right  in  describing  the  right  ovary  as  having  been 
removed  at  the  first  operation ;  and  the  second  operation  not 
only  justified  the  doubt,  but  also  suggested  the  question — which 
even  the  examination  of  the  tumour  by  Dr.  W.  Fox  did  not 
solve — whether  the  tumours  in  either  operation  were  really 
ovarian,  or  fibro-cystic,  or  fibro-sarcomatous  growths,  originating 
in  the  uterus  and  only  involving  the  ovaries.  A  case  such  as 
this,  which,  produced  without  a  retouch  from  the  note-book, 
not  only  shows  the  difficulties  of  diagnosis  encountered  in  the 
emergencies  of  practice,  but  proves  how  perplexing,  even  in 
the  deliberate  investigations  of  the  accomplished  pathologist, 
some  of  the  obscurer  forms  of  disease  may  become,  should  tend 
to  moderate  any  captiousness  of  criticism  in  matters  of  practical 
surgery,  and  open  up  the  way  to  more  minute  and  recondite 
research  into  the  origin  and  forms  of  morbid  changes. 

To  these  four  cases  I  have  now  to  add  nine  others,  making 
thirteen  in  which  I  have  removed  an  ovarian  tumour  from  a 
patient  who  had  previously  undergone  the  operation.  In  eleven 
of  these  patients  I  performed  both  the  operations  myself.  It 
seems  unnecessary  to  give  a  detailed  report  of  the  cases,  but 
the  facts  are  arranged  in  the  table  on  next  page. 

Some  writers  on  ovarian  disease  have  asserted  that  the 
right  ovary  is  much  more  frequently  diseased  than  the  left, 
and  that  coexisting  disease  of  both  ovaries  is  extremely  rare. 
But,  on  examining  the  grounds  for  these  assertions,  we  find 
that  they  are  principally  based  upon  examination  of  patients 
during  life,  or  patients  who  have  not  been  submitted  to  ovari- 
otomy. 

When  we  come  to  examine  the  result  of  post-mortem  ex- 
aminations we  find  (as  a  very  little  reflection  would  lead  one 
to  expect)  that,  as  there  is  no  anatomical  or  physiological 
reason  why  the  right  ovary  should  be  more  frequently  affected 
than  the  left,  so,  in  fact,  one  ovary  is  found  to  be  diseased  as 
often  as  the  other. 

Of  80  cases  collected  by  Dr.  West  from  Scanzoni,  Lee, 
and  his  own  notes  of  post-mortem  examinations,  in  28  the 
disease  was  on  the  right  side,  in  26  on  the  left  side,  and  in 
26  both  ovaries  were  diseased — so  that  in  about  one-third  of 
the  cases  both  ovaries  were  diseased.  In  1865  Scanzoni  again 
drew  attention  to  this  subject  in  the  Wiirzburg  '  Medicinische 


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II 


414  DISEASE    OF   BOTH    OVARIES 

Zeitschrift.'  In  a  paper  '  On  the  Eelation  of  Disease  of  both 
Ovaries  to  the  Ovariotomy  Question,'  he  gives  the  result  of  an 
examination  of  the  reports  of  post-mortem  examinations  for 
the  previous  fourteen  years  by  his  colleagues  Virchow  and 
Forster.  These  records  were  examined  with  the  sole  object  of 
ascertaining  in  how  many  cases  one  or  both  ovaries  were  dis- 
eased— and  in  99  cases  of  ovarian  disease  it  was  found  that  in 
48  one,  and  in  51  both  ovaries  were  diseased — so  that  in  more 
than  half  the  disease  was  on  both  sides.  The  tendency  to 
disease  of  both  ovaries  appears  to  be  greater  before  the  age  of 
fifty  than  in  older  women.  Of  52  women  under  fifty,  both 
ovaries  were  diseased  in  31 ;  one  ovary  only  in  21  (59  per 
cent,  to  40) ;  of  44  women  above  fifty,  both  ovaries  were 
diseased  in  17  only,  while  one  ovary  was  diseased  in  27.  Thus, 
under  fifty,  we  had  both  ovaries  diseased  in  59  per  cent. ; 
above  fifty,  only  in  38  per  cent. 

But  it  must  be  remembered  that  any  conclusion  drawn  from 
post-mortem  examinations  would  in  all  probability  differ  very 
widely  from  results  observed  in  ovariotomy.  The  first  series  of 
facts  shows  what  may  be  expected  when  ovarian  disease  has 
proceeded  to  its  natural  termination,  or  has  only  been  modified 
by  palliative  treatment.  The  other  series  shows  what  may  be 
expected  when  the  patient  is  subjected  to  radical  treatment 
before  the  disease  has  advanced  to  its  last  stages.  All  ob- 
servation tends  to  the  conclusion  that  disease  begins  in  one 
ovary  and  advances  to  a  considerable  extent  in  that  ovary 
before  the  other  is  affected,  and  that  in  about  half  of  the  cases 
it  proceeds  even  to  its  fatal  termination  without  any  disease 
occurring  in  the  opposite  ovary. 

If,  then,  in  only  about  half  of  the  cases  where  ovarian 
disease  has  reached  its  latest  stage,  disease  of  both  ovaries  is 
found,  we  might  expect  that  in  earlier  stages  of  the  disease 
both  ovaries  would  be  much  less  frequently  affected  ;  and  so  far 
as  my  observation  has  gone,  this  is  the  fact.  In  the  1,000 
cases  in  which  I  performed  ovariotomy  I  only  removed  both 
ovaries  in  82  cases.  In  a  few  other  cases  the  ovary  not  re- 
moved presented  some  indications  of  disease  in  a  very  early 
stage,  but  not  sufficient  to  warrant  its  removal. 

It  is  not  improbable  that  in  some  of  the  earlier  cases  slight 
disease  of  the  opposite  ovary  may  have  been  overlooked  ;  but, 


RECURRENCE    OF   DISEASE   IN   REMAINING   OVARY  415 

making  every  reasonable  allowance  for  such  error,  it  is  not 
probable  that  when  ovariotomy  is  performed  both  ovaries  will 
be  found  diseased  in  more  than  about  8  per  cent,  of  the  patients. 
Scanzoni  thinks  that  as  both  ovaries  have  been  so  seldom  re- 
moved (he  finds  only  25  on  record),  operators  must  either  have 
overlooked  disease  of  the  second  ovary  or  thought  it  insig- 
nificant, or  believed  that  the  removal  would  add  too  much  to 
the  danger.  Of  the  25  cases  collected  by  Scanzoni  11  only 
recovered,  and  14  died,  a  mortality  of  56  per  cent. ;  whereas, 
of  468  cases,  where  only  one  ovary  was  removed,  the  mortality 
was  only  44  per  cent.  The  results  of  my  own  experience  may 
be  seen  in  Chapter  X.  Of  the  82  cases  there  recorded,  28  died 
and  54  recovered. 

As  to  the  frequency  with  which,  after  successful  ovariotomy, 
the  ovary  not  removed,  but  examined  and  found  healthy,  be- 
comes diseased,  four  came  under  my  notice  up  to  the  year  1872, 
and  since  1872  there  have  been  nine  others,  as  may  be  seen  at 
page  413,  in  the  table  of  second  operations. 

In  my  second  case,  operated  on  in  1858,  the  patient  re- 
mained well  for  seven  years.  Then  disease  of  the  opposite 
ovary  appeared,  so  evidently  of  a  malignant  character  that  no 
operation  was  thought  of,  and  soft  cancer  was  found  after 
death. 

In  the  third  case,  also  operated  on  in  1858,  the  patient  died 
of  peritoneal  cancer  ten  months  after  operation,  and  disease  had 
commenced  in  the  remaining  ovary,  which  was  enlarged  to  the 
size  of  on  apple. 

In  my  forty-third  case,  operated  on  in  1862,  disease  of  the 
opposite  ovary  came  on  two  years  afterwards,  and  was  treated 
successfully  by  vaginal  tapping  and  drainage.  The  patient 
remained  well  till  1872,  when  Dr.  Sadler,  of  Barnsley,  had 
again  to  give  relief  by  vaginal  tapping.     She  died  in  1874. 


416  LOCAL   CONDITIONS   FOR    GOOD    NURSING 


CHAPTER   XII. 

ON   THE   TREATMENT    OF   PATIENTS   AFTER   OVARIOTOMY 

The  treatment  of  patients  after  ovariotomy  may  be  considered 
under  three  distinct  heads  :  first,  the  condition  under  which 
the  patient  is  placed,  and  the  duties  of  the  nurse ;  secondly, 
the  medical  treatment ;  and  thirdly,  the  surgical  treatment. 

A  large,  lofty,  quiet,  airy  room,  neither  too  hot  nor  too 
cold ;  two  comfortable,  small,  clean  iron  bedsteads,  with  hair 
mattresses,  and  light,  warm  bedding,  so  that  the  patient  may 
be  lifted  from  one  to  the  other,  and  have  a  fresh  bed  every  day ; 
the  personal  linen  so  contrived  that  it  can  be  changed  fre- 
quently without  much  disturbance  of  the  patient;  the  windows 
provided  with  shutters  or  blinds  disposed  so  as  to  admit  only 
an  agreeable  amount  of  light,  or  to  maintain  a  soothing  twi- 
light ;  an  open  fire,  which,  with  an  open  window,  secures  a 
fitting  temperature  with  natural  ventilation ;  a  floor  free  from 
all  woollen  covering  and  the  removal  of  everything  that  could 
prove  offensive  or  hurtful — these  things  together  form  a  com- 
bination of  favourable  conditions  which,  important  in  general 
surgery  and  in  the  treatment  of  every  case  of  severe  illness,  are 
even  more  imperatively  necessary  after  ovariotomy.  It  is  in 
attention  to  minute  details,  and  in  the  observation  of  the  ill- 
effects  which  follow  the  neglect  of  any  of  them,  that  the  prac- 
titioner is  taught  their  importance,  and  learns  how  much  of  his 
success  depends  upon  careful  and  intelligent  obedience  in  those 
who  are  entrusted  with  their  performance. 

The  duties  of  the  nurse  are  to  use  the  catheter  about  every 
six  hours,  or  oftener  if  the  patient  desires  it,  in  order  to  render 
any  movement  or  muscular  effort  in  emptying  the  bladder  un- 
necessary. This  should  always  be  done  for  at  least  three  or 
four  days  ;  and  it  is  often  much  longer  before  a  patient  is  able 
to  dispense  with  the  use  of  the  catheter.     A  silver  catheter 


DUTIES   AND   QUALIFICATIONS   OF   A   NURSE  417 

seems  to  irritate  the  urethra  and  bladder  less  than  an  elastic 
instrument.     Certainly,  troublesome  catarrh  of  the  bladder  is 
more  frequently  noticed  when  an  elastic  catheter  has  been  used, 
probably  because  it  is  not  so  easily  cleansed,  and  some  decom- 
posing mucus,  or  bacteria,  are  introduced  by  it  into  the  bladder. 
A  silver  instrument  is  more  easily  cleansed.     This  should  be 
carefully  and  thoroughly  done  every  time  the  instrument  is 
used,  and  it  should  be  kept  in  carbolized  water.     The  nurse 
should  also  be  quite  capable  of  injecting  into  the  rectum,  either 
small  quantities  of  food,  or  such  doses  of  some  opiate  as  may  be 
found  necessary  to  relieve  pain.     A  succession  of  small  opiates, 
left  to  the  discretion  of  an  intelligent  nurse,  with  directions  to 
give  only  enough  to  keep  the  patient  free  from  severe  pain, 
answer  better  than  larger  doses  administered  at  stated  intervals 
under  medical  prescription.     She  should  be  ready  to  supply  the 
patient  either  with  warm  or  cold  drinks,  or  with  such  light 
nourishment  or  stimulants  as  may  be  directed.     Stimulants, 
such  as  brandy  or  champagne,  must  also  be  left  to  the  nurse, 
but  with  explicit  understanding  that  they  are  only  to  be  used 
when  called  for  by  faintness,  or  chilliness,  or  some  sign  of  ex- 
haustion.    Very  little  food  is  required  during  the  first  three 
days  after  the  operation,  but  there  should  always  be  at  hand  a 
good  supply  of  well-made  barley-water,  toast  and  water,  thin 
gruel,  water  arrow-root,  bread  and  milk,  chicken  broth  or  beef 
tea,  or  any  other  light  nourishment  which  the  patient  may 
fancy.     These  she  may  be  allowed  to  take  almost  as  freely  as 
she   pleases,   provided  she  is   not   sick.     Should   sickness  be 
troublesome,  a  little  brandy  in  iced  soda-water,  or  champagne 
iced,  will  probably  relieve  it ;  but  it  is  often  only  a  sign  of 
weakness,  and  is  then  best  met  by  enemas  of  beef-tea,  either 
with  or  without  egg  and  brandy,  thrown  into  the  rectum,  in 
quantities  of  not  more  than  two  ounces,  at  short  intervals. 
Before  giving  the  injection,  and  at  any  time  when  flatulence  is 
distressing  a  patient,  the  nurse  should  introduce  an  elastic  tube 
or  the  injection  pipe  some  two  or  three  inches  into  the  rectum, 
in  order  that  flatus  may  escape  without  straining  effort,  and 
also  to  allow  of  the  outflow  of  any  previously  injected  and  un- 
absorbed  food.     The  nurse  should  be  able  to  note  variations  of 
the  pulse,  to  take  and  record  temperature  observations  with  the 
thermometer,  at   stated   hours,  or  on   the  occurrence   of  any 

E  E 


418  MEDICAL  TREATMENT   AFTER   OVARIOTOMY 

febrile  symptoms ;  and  in  cases  of  drainage  to  attend  to  the 
cleanliness  of  the  tube,  and  to  draw  off  accumulations  of  fluid, 
or  to  inject  antiseptic  solutions,  although  a  nurse  who  can  be 
trusted  to  do  this  is  an  exceptionally  good  one.  The  nurse 
should  watch  the  urine  of  the  patient,  and  as  soon  as  it  be- 
comes scanty  or  concentrated,  depositing  urates  on  cooling,  she 
should  be  directed  to  give  the  patient  every  two  or  three  hours 
some  lithia  water,  or  a  mixture  of  the  citrates  of  potash  and 
lithia. 

Beyond  this  administration  of  lithia  and  potash,  and  opiates 
in  sufficient  quantity  to  relieve  pain,  medical  treatment  may  be 
said  to  consist  in  doing  no  harm,  providing  the  case  go  on  with- 
out any  serious  complication.  But  if  peritonitis,  either  of  the 
sthenic  or  traumatic  character,  or  of  the  septic  variety,  occur, 
the  fever  accompanying  either  form  of  inflammation  must  be 
watched ;  and  if  the  temperature  of  the  body  as  shown  by  the 
thermometer  rises  considerably  above  the  normal  standard, 
means  must  be  taken  with  the  object  of  lowering  the  tempera- 
ture. Packing  the  arms  and  legs  in  wet  towels — even  the  cold 
bath — have  been  occasionally  used  in  cases  of  hyperpyrexia,  but 
generally  iceing  the  head  continuously  is  far  less  disturbing  to 
the  patient,  and  even  more  efficacious.  I  have  tried  the  "cushions 
made  of  tubes  for  iced  water,  introduced  by  Dr.  Koberts,  of 
Manchester,  and  icebags  for  the  neck,  after  Dr.  Richardson — 
but  prefer  Mr.  Thornton's  ice-cap  for  the  head  to  any  other 
arrangement.  Before  antiseptics  the  head  was  kept  cool  for  a 
day  or  two  in  about  half  the  cases.  Since  antiseptics  I  have 
scarcely  ever  found  it  necessary. 

The  bowels  are  kept  quiet  after  the  operation ;  and  as  long 
as  the  patient  feels  comfortable,  their  action  need  not  be 
brought  on,  even  if  they  do  not  act  for  ten  days  or  more.  I 
have  known  them  nineteen  days  without  acting,  and  then  act 
naturally  without  any  painful  effort.  An  enema  of  warm  water 
or  a  dose  of  castor  oil  will  bring  on  their  action  if  not  sponta- 
neous. Accumulation  of  hard  fascal  masses  in  the  rectum  may 
cause  tenesmus,  keep  up  a  spurious  diarrhoea,  and  thus  render 
the  patient  uncomfortable.  Their  presence  will  be  discovered 
by  digital  examination.  They  should  be  broken  up  with  the 
finger  or  a  spoon,  and  the  bowels  afterwards  cleared  by  inject- 
ing warm  water.     If  the  first  motion  fatigues  the  patient  and 


SURGICAL   TREATMENT   AFTER   OVARIOTOMY  419 

renders  her  restless,  it  will  be  advisable  to  have  it  followed  by 
an  opiate  enema.  Vomiting  is  often  a  troublesome  symptom, 
less  so  when  methylene  has  been  used  than  after  chloroform. 
It  is  sometimes  relieved  by  giving  small  pieces  of  ice  to  suck, 
or  to  swallow  as  ice  pills  ;  sometimes  by  draughts  of  hot  water. 
Of  all  medicines,  I  have  found  15  grain  doses  of  bromide  of 
potassium  in  two  ounces  of  water  the  most  useful.  Next  to 
that,  three  to  five  drops  of  prussic  acid  ;  but  this  is  sometimes 
dangerous  by  leading  to  accumulations  of  large  quantities  of 
fluid  in  the  stomach.  If  this  accumulation  and  consequent 
faintness  are  observed,  it  may  be  necessary  to  empty  the 
stomach  by  the  stomach-pump. 

Flatulence,  often  a  very  troublesome  symptom,  may  be  re- 
lieved by  passing  the  elastic  tube  of  an  enema  apparatus  up 
the  rectum.  An  enema  of  five  grains  of  quinine  in  an  ounce  of 
water,  with  or  without  a  few  drops  of  laudanum,  repeated  every 
four  hours,  has  often  relieved  flatulence  by  restoring  the  tone 
of  the  muscular  coat  of  the  intestines,  and  occasionally  Faradi- 
sation has  proved  useful  in  the  same  way.  A  few  drops  of 
chloric  ether  and  salvolatile  sometimes  give  relief,  and  tincture 
of  nux  vomica  has  appeared  to  be  of  use  in  some  cases. 

Surgical  treatment. — The  various  conditions  following 
ovariotomy  which  may  call  for  surgical  treatment  may  be 
arranged  in  order,  commencing  with  the  wound  in  the  abdo- 
minal wall  and  the  separation  of  the  pedicle ;  collections  of 
serum,  blood,  or  pus  in  some  part  of  the  peritoneal  cavity ; 
adhesions  between  the  intestine  and  the  pedicle,  or  the  ab- 
dominal wall,  leading  to  intestinal  obstruction. 

Unless  the  abdominal  wall  is  oedematous,  or  the  dressing  is 
moistened,  it  is  better  not  to  disturb  the  bandage  or  plaster 
until  the  seventh  day  after  operation.  And  then  it  is  not 
necessary  to  raise  the  plaster  from  the  sides  of  the  abdomen : 
it  should  be  raised  and  divided  with  scissors  two  or  three  inches 
on  one  side  of  the  wound,  then  raised  and  divided  on  the  other 
side.  In  this  way  the  wound  may  be  uncovered  without  dis- 
turbing the  patient.  After  removing  the  gauze,  the  plaster  left 
on  either  side  is  used  as  splints,  and  drawn  together  by  new 
plaster  above  and  below  the  wound  so  as  to  take  off  all  tension 
from  the  wound  as  the  stitches  are  removed.  As  a  rule,  union 
takes  place  without  any  suppuration,  but  occasionally  a  little 

k  rc  2 


420  MANAGEMENT  OF  THE  SUTURES 

pus  will  exude  from  one  or  more  of  the  points  of  suture.  This 
may  cause  a  little  feverishness,  but  is  not  of  much  consequence. 
Indeed,  since  antiseptics  it  is  very  rare  to  see  even  a  single 
drop  of  pus.  Three  or  four  times,  before  the  antiseptic  period, 
I  have  seen  considerable  collections  of  pus  in  the  abdominal 
wall,  almost  always  in  very  fat  patients.  In  such  cases  care 
must  be  taken  to  avoid  any  dressing  which  would  interfere 
with  the  free  escape  of  the  pus.  A  pad  of  boracic  cotton  should 
be  placed  over  the  wound,  and  support  given  by  strips  of 
plaster,  which  draw  up  the  side  pieces  or  splints.  Koeberle 
uses  cotton  threads  steeped  in  collodion  with  the  same  object. 

In  every  case  after  removal  of  the  sutures,  the  abdomen 
should  be  supported  by  adhesive  plaster  for  at  least  a  fortnight, 
or  until  the  wound  is  firmly  agglutinated.  Tympanites,  hiccup, 
and  vomiting  might  separate  the  edges  of  a  wound  which  had 
united  fairly  well,  if  these  edges  were  not  well  supported.  In  a 
few  cases  I  have  seen  more  or  less  reopening  of  the  wound ; 
in  two  the  sutures  were  removed  too  early,  and  the  abdominal 
walls  were  not  supported  by  plaster ;  in  other  two  cases  there 
was  pyaemia  or  septicaemia,  and  the  plastic  process  was  slow  on 
account  of  the  state  of  the  blood ;  in  other  two  cases  the  acci- 
dent was  caused  by  violent  cough  on  the  seventh  or  eighth  day, 
a  day  or  two  after  the  stitches  had  been  removed.  These  two 
patients  recovered,  the  others  died.  I  have  also  seen  other 
cases  where  partial  reopening  of  the  wound  has  appeared  to  do 
good  by  admitting  of  the  escape  of  serum.  In  all,  the  stitches 
were  replaced  as  soon  as  I  was  aware  of  the  occurrence. 

Unless  the  pedicle  is  very  short,  if  a  clamp  has  been  used 
it  lies  across  the  lower  part  of  the  wound,  without  any  depres- 
sion of  the  abdominal  wall,  and  the  patient  is  quite  unconscious 
of  its  presence.  Sometimes,  with  a  very  short  pedicle,  the 
clamp  and  the  integuments  have  been  drawn  almost  down  to  the 
sacrum,  even  then,  without  much  complaint  from  the  patient. 
There  has  sometimes  been  protrusion  of  the  pedicle  behind  the 
clamp,  separating  the  lower  edges  of  the  wound.  When  this 
occurs,  the  lowest  stitch  should  be  removed,  as  the  protrusion 
is  due  to  obstructed  return  of  blood  through  the  veins  of  the 
pedicle.  Two  or  three  times  the  protrusion  has  been  so  great 
that  I  have  passed  a  pin  through  the  pedicle  behind  the  clamp, 
tied  a  ligature  below  the  pin,  and  cut  away  both  clamp  and 


CLAMP   AND   PEDICLE 


421 


pedicle ;  but  this  was  seldom  necessary,  as  the  swelling  sub- 
sides soon  after  the  removal  of  the  compression  caused  by  the 
too  tight  stitch.  The  clamp  and  the  portion  of  pedicle  com- 
pressed by  it  generally  fell  off  from  the  seventh  to  the  tenth 
day,  sometimes  as  early  as  three  or  four  days,  and  sometimes 
not  for  fifteen  or  more.  It  is  important  not  to  remove  the 
clamp  too  soon,  especially  if  the  pedicle  is  short,  as  the  newly 
formed  adhesions  between  the  pedicle  and  the  abdominal  wall 
might  give  way,  and  the  pedicle  sink  into  the  peritoneal  cavity, 
possibly  giving  rise  to  septic  peritonitis  and  death,  and  probably 
leaving  an  opening  which,  after  healing  of  the  skin,  would  admit 
of  the  easy  production  of  a  ventral  hernia.  But  when  the  clamp 
is  only  held  by  a  few  shreds  of  dead  tissue,  it  may  be  removed. 
A  little  ulceration  of  integument  from  pressure  of  the  clamp 
should  not  lead  to  the  premature  removal  of  the  clamp,  as  this 
is  of  far  less  consequence  than  the  risk  of  removing  the  clamp 


too  soon.  This  woodcut,  copied  from  a  photograph  taken  by 
L)r.  Wright,  shows  the  ordinary  appearance  of  the  abdomen  with 
the  cicatrix  in  a  young  person  three  weeks  after  operation. 


422  COLLECTION   OF   FLUID   IN   THE   PERITONEUM 

Where  a  clamp  has  not  been  used,  but  the  patient  has  been 
treated  by  one  or  other  of  the  intra-peritoneal  methods,  union 
by  the  first  intention  along  the  whole  length  of  the  incision  is 
usually  complete.  The  delay  in  the  union  at  the  lower  angle 
of  the  wound,  where  the  remains  of  the  pedicle  are  fixed,  may 
protract  the  complete  cicatrization  to  the  third  or  fourth  week, 
but  this  is  of  little  consequence,  and  need  not  interfere  with 
the  movement  of  the  patient. 

When  bad  symptoms  follow  ovariotomy — pain,  vomiting, 
fever  with  abdominal  distension — the  surgeon  should  suspect 
that  some  fluid,  either  serum,  blood,  or  pus,  is  collecting  in  the 
peritoneal  cavity.  It  may  collect  in  such  quantity  as  to  give 
rise  to  sensible  fluctuation  from  one  side  of  the  abdomen  to 
the  other ;  or  it  may  gravitate  to  the  bottom  of  Douglas's  space, 
and  form  a  tense  swelling  behind  the  uterus,  easily  felt  through 
the  vagina,  although  there  may  be  no  free  fluid  perceptible  in 
the  abdominal  cavity.  If  the  pedicle  has  been  treated  by 
ligature,  the  ends  of  the  ligature  passing  outwards  then  serve 
as  drainage  conductors,  and  a  very  free  discharge  of  fluid  may 
go  on  for  several  days.  Koeberle  prepares  for  drainage  by 
introducing  strong  perforated  glass  tubes,  and,  by  the  aid  of  a 
syringe  fitted  to  the  tubes,  he  withdraws  fluid  several  times 
daily.  Peaslee  has  advocated  and  adopted  with  success  this 
system  of  drainage,  with  the  addition  of  repeated  washings  out 
of  the  peritoneum  with  warm  water  and  disinfecting  solutions. 
In  a  few  bad  cases  I  have  also  followed  this  practice,  but  never 
with  success. 

In  most  of  the  cases  reported  by  Peaslee  as  treated  with 
peritoneal  injections,  the  pedicle  was  dealt  with  after  the  oldest 
method  :  that  is,  it  was  transfixed,  each  half  was  tied,  and  the 
ends  of  the  ligatures  were  allowed  to  hang  out  of  the  wound. 
In  one,  the  ligatures  were  brought  out  through  a  vaginal 
canula.  In  all,  the  convalescence  was  very  tedious,  and  three 
had  septicaemia.  The  most  remarkable  of  the  whole,  as  regards 
the  treatment,  was  that  in  which  one  hundred  and  thirty  injec- 
tions were  made  into  the  peritoneal  cavity  in  seventy-eight 
days.  The  last  ligature  came  away,  and  pus  ceased  to  be  se- 
creted, on  the  ninety-fourth  day  after  operation. 

Whenever  fluid  can  be  detected  by  vaginal  examination 
in  the  neighbourhood  of  the  uterus  it  is  usually  in  such  quan- 


DRAINAGE    AND    INJECTIONS 


423 


tity  that  it  must  be  removed;  and  this  is  done  either  by 
Scanzoni's  trocar,  the  straight  instrument,  with  triangular 
canula,  here  shown,  or  by  a  curved  trocar,  over  which  an  elastic 
catheter  is  fixed,  instead  of  a  canula  ;  or  by  a  trocar  still  more 


curved  a  piece  of  drainage  tube  may  be  inserted  and  fastened, 
as  shown  in  the  next  cut.  I  introduced  this  tube  in  the 
following  case,  where  it  led  to  free  discharge,  which  was  followed 
by  complete  recovery. 

An  unmarried  girl,  eighteen  years  of  age,  was  sent  to  me 
by  Dr.  Whitehead,  of  Manchester,  as  a  favourable  case  for 
ovariotomy,  and  was  admitted  to  the  Samaritan  Hospital  on 


June  5,  1864.  The  disease  dated  from  the  commencement  of 
the  catamenia,  five  years  before,  and  six  months  after  a  leg  had 
been  broken.  Increase  had  been  rapid  at  first,  but  latterly 
slow.  She  had  not  been  tapped.  A  point  of  great  interest  in 
diagnosis  was  observed  in  this  case  :  the  tumour  was  observed 
to  move  very  freely  beneath  the  abdominal  parietes  on  deep 
inspiration,  and  I  therefore  expected  to  find  a  non-adherent 
tumour ;  but  at  the  operation  very  firm  adhesions  had  to  be 


424  CASE   OF   DRAINAGE 

separated.  They  were,  however,  sufficiently  long  to  admit  of 
the  cyst  moving  freely.  Ovariotomy  was  performed  on  June 
13.  Dr.  Parson  gave  chloroform.  On  making  an  incision  four 
inches  long  midway  between  the  umbilicus  and  symphysis 
pubis,  three  small  cysts  filled  with  gritty  matter  were  exposed 
in  the  cellular  tissue  between  the  sheath  of  the  recti  and  the 
peritoneum.  These  were  dissected  out.  Long  and  very  firm 
adhesions  anteriorly  and  in  the  right  iliac  fossa,  and  a  very 
extensive  surface  of  adherent  omentum,  were  separated  by  the 
hand  with  some  difficulty,  and  a  close  adhesion  to  the  fundus 
of  the  bladder  was  separated  by  very  careful  dissection.  Eleven 
pints  of  fluid  were  removed  by  the  trocar.  The  ovary  appeared 
normal,  while  the  tumour  was  attached  to  its  external  angle  by 
a  narrow  pedicle,  about  one  inch  in  length.  The  ovary  was. 
however,  removed  with  the  tumour.  A  small  pedicle  was  se- 
cured close  to  the  uterus  by  a  silk  ligature,  which  was  cut  off 
short  and  returned.  There  was  very  little  bleeding,  and  the 
wound  was  closed  in  the  usual  manner.  The  stitches  were 
removed  forty-four  hours  after  operation,  the  wound  being 
perfectly  united.  On  the  third  day  alter  operation  some  sharp 
pain  came  on,  which  became  easier  after  a  uterine  discharge 
like  menstruation  appeared.  She  continued  doing  well  till  the 
22nd  (ninth  day),  when,  after  a  sleepless  night  from  pain  and 
flatulence,  she  was  found  in  a  state  resembling  typhus  fever — 
dry  tongue,  dilated  pupils,  flushed  face,  and  drowsiness.  As 
this  condition  became  more  decided  in  the  afternoon,  I  exa- 
mined by  the  vagina  and  rectum,  and,  detecting  fluid  between 
them,  made  a  puncture  by  a  trocar,  and  let  out  five  ounces  of 
dark  bloody  serum  which  had  a  putrid  ammoniacal  odour.  This 
was  followed  by  some  relief.  The  pulse  sank  from  112  to  95 
and  92,  but  mucous  diarrhosa  came  on,  and  the  typhoid  condi- 
tion was  aggravated  next  day.  As  the  discharge  from  the 
trocar  puncture  had  ceased,  and  examination  detected  fluid 
still  in  the  recto-vaginal  space,  I  made  another  opening  into  it, 
and  evacuated  ten  ounces  of  fluid  still  more  putrid  than  that  of 
the  day  before,  and  containing  pus.  I  then  carried  on  the 
trocar  through  the  opening  made  the  day  before,  and  drew  a 
drainage  tube  through  the  canula  before  withdrawing  it.  The 
tube  was  then  tied  and  left  fixed,  as  shown  in  the  diagram. 
I  took  great  care  that  it  should  pass  through  the  lowest  point 


OBSTKUCTED   INTESTINE  425 

where  the  peritoneum  is  reflected  from  the  rectum  to  the 
vagina.  Very  free  discharge  came  through  the  tube  for  several 
days,  and  the  general  condition  rapidly  improved.  The  tongue 
and  mouth  were  covered  with  aphthous  spots  for  several  days, 
and  diarrhoea  was  troublesome.  But  the  tube  was  removed  on 
July  1,  and  convalescence  was  rapid.  She  was  sitting  up  on 
the  6th,  and  was  to  leave  for  the  country  on  the  14th.  She 
went  to  the  Seaside  Convalescent  Home  at  Eastbourne,  re- 
mained there  a  month,  and  returned  in  perfect  health. 

The  result  of  my  experience  is,  that  the  danger  of  puncture 
has  been  very  greatly  exaggerated;  that  the  benefit  of  the 
evacuation  of  fluid  is  often  very  marked ;  and  that  any  danger 
arises  from  too  early  closing  of  the  opening,  not  from  the  open- 
ing having  been  made.  Where  it  is  not  easy  to  pass  a  drainage 
tube,  or  where  it  is  desired  to  use  antiseptic  injections  as  well 
as  drain,  it  is  better  to  leave  a  silver  canula  in  Douglas's  pouch, 
and  to  keep  it  there  by  the  spring  of  double  silver  wire  as 
shown  in  the  drawing  at  page  169.  It  passes  out  through  the 
vagina,  and  injections  may  easily  be  thrown  through  it.  But 
this  is  one  of  the  troublesome  details  of  after-treatment  which 
has  become  extremely  rare  since  the  adoption  of  antiseptics. 

The  most  alarming  symptoms  which  occur  after  ovariotomy 
are  those  which  depend  upon  obstructed  intestine.  I  heard  of 
one  case  which  has  never  been  recorded,  where  a  loop  of  in- 
testine slipped  through  one  of  the  loops  of  wire  used  as  sutures 
for  the  wound,  and  was  tightly  compressed  when  the  wire  was 
fastened.  In  a  published  case,  there  is  very  little  doubt  that  a 
faecal  fistula  was  caused  by  perforation  of  intestine  with  the 
stitch  closing  the  wound.  In  one  of  my  early  cases,  a  coil  of 
intestine  was  compressed  between  the  pedicle  and  the  abdo- 
minal wall,  and  I  have  seen  others  since,  where  the  same  acci- 
dent would  have  happened  if  I  had  not  been  on  my  guard. 
After  the  intra-peritoneal  methods  of  dealing  with  the  pedicle 
by  ligature  and  by  cautery,  I  have  seen  fatal  obstruction  of  the 
intestine  caused  by  adhesion  of  coils  of  intestine  around  the 
divided  end  of  the  pedicle  at  such  sharp  angles  that  the  canal 
was  quite  closed ;  and  I  have  seen  adhesion  of  intestine  to  a 
pedicle  secured  by  the  clamp  lead  in  the  same  way  to  obstruc- 
tion. The  following  case  illustrates  the  course  of  the  symptoms 
when  this  dangerous  complication  presents  itself: — 


426  CASE    OF   OBSTRUCTED   INTESTINE 

A  single  woman,  thirty-five  years  old,  was  sent  to  me  by 
Dr.  Giles,  of  Oxford,  and  was  admitted  to  hospital  in  March 
1867.  The  whole  abdomen  was  filled  by  a  multilocular  ovarian 
cyst.  The  uterus  was  healthy,  and  its  mobility  free.  Ovari- 
otomy was  performed  on  March  27.  A  pedicle,  two  to  three 
inches  broad  at  its  narrowest  part,  and  about  one-third  of  an 
inch  thick,  connected  the  base  of  the  tumour  closely  to  the 
right  side  of  a  small  hard  uterus,  of  irregular  shape  from  a 
fibroid  nodular  outgrowth.  A  cautery  clamp  was  applied,  and 
the  pedicle  separated  by  hot  irons.  On  opening  the  clamp, 
the  compressed  and  seared  pedicle  appeared  at  first  quite 
secure.  But  as  the  pedicle  was  slowly  separating  from  the 
blade  of  the  clamp  to  which  it  adhered,  three  vessels  bled 
freely.  These  were  tied,  and  then,  as  there  was  some  oozing 
of  blood  all  along  the  line  of  eschar,  I  transfixed  the  pedicle 
close  to  the  uterus,  tied  the  pedicle  in  two  halves,  and  allowed 
it  to  sink  into  the  abdomen,  after  cutting  off  the  ends  of  the 
ligature  short.  Scarcely  any  sponging  was  necessary,  as  no 
ovarian  fluid  had  entered  the  peritoneal  cavity.  The  left 
ovary  was  healthy.  Eighteen  pints  of  colloid  fluid  were  re- 
moved, and  the  more  solid  portion  of  the  tumour  weighed  five 
pounds. 

On  examining  the  root  of  the  tumour  after  removal,  seven 
or  eight  arteries  as  large  as  a  crowquill  were  observed  entering 
the  tumour  and  forming  numerous  corkscrew-like  ramifications. 
Dr.  Junker  found  a  number  of  yellow  tubercles  imbedded  in 
the  stroma  of  the  tumour — both  in  the  periphery  and  near  the 
base — separate,  as  minute  yellow  and  greyish-yellow  spots ;  and 
confluent,  of  the  consistence  of  cheese. 

The  state  of  the  patient  after  operation  was  unsatisfactory 
from  the  first,  but  there  was  not  much  pain.  Some  sickness 
on  the  day  after  operation  increased  on  the  second  day,  and  the 
abdomen  became  tympanitic.  On  the  third  and  fourth  days 
the  vomiting  continued,  a  great  deal  of  dark  green  or  coffee- 
coloured  fluid  being  thrown  up.  A  free  fluid  motion  was 
followed  on  the  fifth  and  sixth  days  by  some  improvement, 
although  the  vomiting  of  large  quantities  of  greenish  fluid 
continued.  On  the  seventh  morning  the  patient  appeared 
much  better;  but  in  the  evening  the  pulse  was  160,  and  she 
appeared  almost  moribund.     Five  grains  of  quinine  were  given 


POST-MORTEM   EXAMINATION 


427 


every  three  hours  by  mouth  and  rectum.  In  sixteen  hours 
thirty-five  grains  had  been  given,  and  on  the  eighth  day  the 
pulse  had  fallen  to  ]  20.  In  the  next  ten  days  she  improved  in 
many  respects.  There  was  no  vomiting,  but  she  suffered  at 
times  with  abdominal  pain  and  much  flatulence.  On  the  nine- 
teenth day  she  appeared  remarkably  well ;  but  at  night,  after 
a  free  watery  motion,  she  suddenly  became  faint  and  sick,  and 
died  on  the  morning  of  the  twentieth  day. 

The  wound  was  found  firmly  united.     There  were  scarcely 
any  traces  of  general  peritonitis.     No  intestine  was  adherent 


near  the  wound,  but  one  coil  slightly  adhered  above  the  um- 
bilicus. The  uterus  was  small,  and  had  a  fibroid  nodule  the 
size  of  a  marble  projecting  from  its  fundus.  The  left  ovary 
was  healthy.  The  pedicle  of  the  tumour  of  the  right  ovary 
was  closely  surrounded — as  shown  in  the  accompanying  en- 
graving, copied  from  a  drawing  made  by  Dr.  Junker — by  an 
adhering  coil  of  the  ileum  just  before  it  enters  the  caecum. 
About  an  ounce  of  pus  was  circumscribed  by  this  adhering 
intestine  around  the  end  of  the  pedicle,  so  that  none  of  the 


428  OBSTRUCTION    FOLLOWED 

pus  entered  the  peritoneal  cavity.  The  canal  of  the  adhering 
coil  of  intestine  was  almost  completely  obstructed,  partly  by  the 
sharp  curves  at  which  it  was  fixed,  and  partly  by  the  contrac- 
tion of  the  adhering  portion,  the  intestine  above  being  much 
distended.  There  was  neither  blood,  lymph,  nor  serum  in  the 
peritoneal  cavity,  nor  could  any  tubercular  deposit  be  found. 

An  interesting  case,  which  I  had  seen  with  Dr.  Bantock 
at  the  Samaritan  Hospital,  is  reported  by  Mr.  Doran  in  the 
'  Transactions  of  the  Pathological  Society  for  1879,' vol.  xxx. 
The  obstruction  in  the  intestine  was  followed  by  perforation 
and  death.  Some  weeks  before  her  admission  into  the  hospital, 
the  patient  had  been  ill  with  fever  followed  by  symptoms  of 
peritonitis,  and  during  the  operation  for  removal  of  a  suppu- 
rating ovarian  cyst  Dr.  Bantock  found  that  the  hinder  part  of 
the  tumour  was  closely  adherent  to  eight  or  ten  inches  of  the 
lower  portion  of  the  ileum.  The  adhesions  were  broken  down 
with  sponges  and  six  small  open  vessels  were  secured  by  liga- 
ture. At  the  end  of  two  days  the  temperature  rose  and  there 
were  signs  of  intestinal  mischief.  On  the  eighth  day  the 
woman  died  in  a  state  of  collapse.  The  post-mortem  showed 
a  coil  of  ileum  partly  adherent  to  the  abdominal  wall,  which  as 
soon  as  it  was  raised  gave  issue  to  fluid  fseces  through  a  per- 
foration of  its  coat  posteriorly,  as  it  had  already  done  to  the 
extent  of  a  pint  during  life.  Above  this  point,  the  small 
intestine  was  filled  with  flatus  and  faeces ;  below  it,  the  remainder 
of  the  ileum,  as  far  as  to  within  three  inches  of  the  ileo-ccecal 
valve,  was  matted  together  by  recent  lymph  on  the  serous 
coat — the  site  of  the  former  adhesion  to  the  back  of  the  cyst. 
This  obstructed  mass,  much  narrowed  and  quite  empty,  hung 
down  over  the  promontory  of  the  sacrum.  The  end  of  the 
ulcerated  coil,  being  full  of  flatus,  had  risen  so  that  its  free 
border  almost  touched  the  mesentery  above.  Hence  the 
intestine  was  sharply  twisted  at  the  point  where  this  coil  joined 
the  dependent  obstructed  mass.  This  complication,  evidently 
secondary,  made  the  obstruction  complete.  The  perforating 
ulcer  was  nearly  a  foot  above  the  twist  in  the  ileum,  with 
clean-cut  edges,  but  thickened.  The  muscular  coat  was  ex- 
posed and  also  perforated,  and  in  the  serous  coat  there  was  a 
hole  one  eighth  of  an  inch  in  diameter.  Perforation  was 
commencing  in  several  neighbouring  ulcers,  but  there  was  no 


BY   PERFORATION 


429 


trace  of  ulceration  in  Peyer's  patches.  A  preparation  of  the 
parts,  made  by  Mr.  Doran,  is  now  in  the  pathological  series  of 
the  museum  of  the  College  of  Surgeons  (No.  1,201  B). 

In  all  these  cases  the  symptoms  are  exactly  those  of  stran- 
gulated hernia.  They  may  be  relieved  by  opium  or  bella- 
donna, but  are  almost  certainly  fatal  if  the  obstruction  cannot 
be  overcome.  More  than  once  I  have  reopened  the  abdomen 
and  separated  adhering  intestine  from  the  pedicle,  with  tem- 
porary relief,  but  new  adhesions  followed  and  ultimately  death. 
I  have  seen  several  cases  where  symptoms  of  obstruction  have 


gradually  disappeared,  and  this  has  led  me  to  wait  too  long  in 
other  cases  before  reopening  the  wound  and  searching  for  the 
seat  of  obstruction.  In  one  case  I  might  easily  have  saved 
life  by  separating  a  mere  film  of  adhesion  close  to  the  wound, 
which  held  a  piece  of  small  intestine  as  sharply  as  a  ligature. 
The  preparation  is  in  the  Museum  of  the  College  of  Surgeons. 
These  two  woodcuts  serve  to  make  clear  a  point  in  anatomy 


430 


SMALL  INTESTINES 


which,  from  being  overlooked  or  forgotten,  has  often  led  to 
difficulties  in  diagnosis  and  sometimes  to  dangerous  proposals, 
or  mischievous  practice.  It  will  be  seen  by  the  representation 
of  the  perpendicular  section  of  the  abdomen,  pelvis,  and  their 
contents,  how  under  certain  circumstances  Douglas's  pouch  may 
become  distended  by  fluid  or  by  a  mass  of  intestines  gravitating 
into  it.  To  be  able  to  make  sure  of  the  nature  of  the  tumefaction 
thus  caused,  and  perceived  during  vaginal  examination,  requires 
tact  and  experience,  and  I  have  not  been  surprised  sometimes 
to  hear  most  erroneous  speculations  about  it  and  to  find  myself 
consulted  as  to  operative  measures  for  its  relief,  under  what  was 


supposed  to  be  the  most  urgent  necessity.  But  a  study  of  the 
relations  of  the  parts  will  show  how  the  presence  of  small  intes- 
tines filled  with  faecal  matter  and  falling  low  down  into  Douglas's 
pouch  between  the  uterus  and  rectum  may  simulate  abscess  or 
hematocele.  The  drawing  also  explains  what  a  scope,  when  the 
expansion  of  the  pouch  has  once  begun,  the  space  offers  for  the 
enlargement  of  a  cystic  tumour  in  that  direction,  and  how  by 
remaining  for  some  time  undisturbed  it  may  so  model  itself 
to  the  form  of  the  pelvis  and  to  the  outline  of  the  organs  in 
it,  as  to  be  raised  with  difficulty  and  to  give  cause  to  fear 
the   presence   of  serious  attachments.     All  this  explains  one 


IN   DOUGLAS'S   POUCH  431 

cause  of  obstructed  intestine  which  has  hitherto  escaped 
notice.  Adhesion  of  coils  of  intestine  to  the  pedicle,  to  the 
abdominal  wall,  or  to  neighbouring  coils  of  intestine  at  such 
sharp  curves  or  angles  as  to  close  the  canal  have  been  referred 
to ;  but  the  fact  that  this  adhesion  may  take  place  low  down 
in  the  pelvis  at  the  bottom  of  the  recto-uterine  pouch  has  not 
been  mentioned.  Still,  it  is  not  very  rare,  and,  though  easily 
recognized  when  understood,  it  may  easily  be  mistaken  for 
abscess  or  hsematocele.  The  first  of  these  two  drawings  shows 
how  in  most  adults  some  portion  of  the  small  intestines  sinks 
down  in  the  normal  condition  of  parts  between  the  uterus  and 
the  rectum.  After  ovariotomy,  especially  when  the  lower  part 
of  the  ovarian  tumour  has  pushed  the  uterus  upwards  and 
forwards,  a  considerable  space  is  often  left  between  the  rectum 
and  uterus,  and  into  this  the  small  intestines  fall  down.  I 
have  very  often  found  them  there  when  sponging  out  the  pelvis. 
Now,  supposing  them  to  be  more  or  less  firmly  fixed  there  by 
effused  lymph,  it  is  very  probable  that  some  obstruction  may 
follow,  and  that  a  considerable  swelling  may  be  discovered 
behind  the  uterus  on  examining  by  the  vagina.  Eectal  ex- 
amination at  once  shows  that  it  is  between  the  rectum  and  the 
uterus,  and  probably  that  it  is  more  towards  the  right  than  the 
left  side.  A  glance  at  the  second  of  these  woodcuts  shows  why 
this  is  so.  The  rectum,  containing  faeces,  fluid,  or  gas,  occu- 
pies the  left  side  before  it  reaches  the  middle  line,  and  there  is 
more  vacant  space  towards  the  right  of  Douglas's  pouch  to  admit 
the  small  intestines.  There  they  may  adhere  and  form  a  con- 
siderable tumour. 

Sometimes,  long  after  recovery,  more  or  less  complete  ob- 
struction of  intestine  is  followed  by  the  formation  of  a  fsecal 
fistula.  Such  cases  are  recorded  by  Dr.  Lyon,  of  Glasgow,  Dr. 
Keith,  of  Edinburgh,  and  Mr.  Bryant.  Once  the  same  thing 
happened  in  a  patient  of  my  own.  In  Dr.  Lyon's  case  the  opera- 
tion was  performed  in  February  1866,  '  easily  and  favourably.' 
Hiccup  and  severe  vomiting  were  present  for  a  few  days,  and 
it  was  afterwards  found  that  union  of  the  edges  of  the  wound 
was  imperfect.  A  portion  of  intestine  was  to  be  seen  adherent 
at  the  bottom  of  the  wound.  Pin-like  perforations  took  place 
in  this,  and  gave  issue  to  fsecal  matter  and  offensive  gas. 
Various  means  were  taken  to  obtain  healing,  but  in  August 


432  CASES   OF   F.ECAL   FISTULA 

1867  the  wound,  or  rather  the  small  exposed  portion  of  per- 
forated intestine,  remained  unchanged. 

Dr.  Keith  operated  on  a  patient,  aged  thirty-two,  in  October 
1865.  Both  ovaries  were  removed,  the  pedicle  of  the  second 
being  so  short  that  it  was  tied  with  silk  ligatures,  the  ends  cut 
off  short.  The  patient  recovered  rapidly,  and  at  the  end  of 
six  weeks  was  quite  well.  She  then  began  to  have  pain  and 
irritation  in  the  pelvis,  and  in  December  pelvic  abscess  formed 
and  pointed  a  little  above  Poupart's  ligament.  By  January 
1867  the  opening  was  almost  closed,  but  the  following  May 
there  was  a  sudden  escape  of  coagulated  blood  from  the  rectum, 
followed  by  a  free  discharge  of  pus  from  the  opening  in  the 
groin.  Faecal  matter  soon  made  its  appearance,  and  continued 
to  flow  till  July,  when  the  fistula  finally  closed.  This  is  the 
only  case  of  the  kind  which  has  fallen  to  Dr.  Keith,  and  it 
was  also  the  only  one  in  which  at  the  time  he  published  the 
case  he  had  returned  the  pedicle  with  the  ligatures  into  the 
abdomen  after  ovariotomy. 

Mr.  Bryant's  was  a  case  of  successful  ovariotomy  in  1867. 
The  pedicle  was  transfixed  and  tied  with  whipcord ;  the  ends 
of  the  ligature  being  cut  off,  they  were  allowed  to  sink  into 
the  abdomen  with  the  pedicle.  These  ligatures  were  discharged 
some  months  afterwards  through  an  artificial  anus  at  the  lower 
part  of  the  abdominal  wound,  which  in  the  end  healed  up  com- 
pletely. 

The  operation  in  my  case  was  performed  on  March  10, 
1864.  The  patient  was  fifty-seven  years  of  age.  She  had 
been  tapped  three  times,  and  had  suffered  from  several  attacks 
of  circumscribed  peritonitis.  A  large  multilocular  cyst  of  the 
left  ovary  was  removed.  It  had  so  displaced  the  uterus  that 
the  pedicle  seemed  to  be  on  the  right  side,  but  it  afterwards 
appeared  that  the  right  ovary  was  healthy.  The  pedicle  was 
transfixed,  each  half  tied  separately,  the  whole  surrounded  by 
a  third  ligature ;  and  the  tied  end,  after  separation  of  the 
tumour,  was  returned  into  the  abdomen  with  the  ligatures, 
the  ends  of  which  were  cut  off  short,  close  to  the  knots.  A 
portion  of  the  cyst  adhered  so  firmly  in  the  left  iliac  fossa  that 
it  could  not  be  separated,  and  it  was  left  adherent,  after  trans- 
fixing and  tying  it,  leaving  the  ends  of  the  ligature  hanging  out 
of  the  lower  angle  of  the  wound.     The  patient  recovered,  and 


CASE   OF    F^CAL    FISTULA  433 

went  to  Leeds,  five  weeks  after  the  operation,  the  ligatures  still 
keeping  the  lower  part  of  the  wound  open,  and  a  little  discharge 
daily  escaping  beside  them.  She  bore  the  journey  well,  and  im- 
proved till  May  6,  when,  after  fatigue,  she  had  a  severe  rigor, 
followed  by  vomiting  and  bilious  diarrhoea.  Fever  and  profuse 
perspiration  followed,  and  the  discharge  became  more  abundant 
along  the  track  of  the  ligature.  On  May  10,  1864,  the  late  Mr. 
Teale,  of  Leeds,  wrote  :  '  Yesterday  evening  the  discharge  was 
evidently  feculent,  and  continues  so  to-day.'  On  the  11th  he 
wrote :  '  The  discharge  is  now  simply  purulent,  without  any 
stain  of  faecal  matter;  The  ligature  has  yielded  considerably 
this  morning,  but  is  not  quite  at  liberty.'  On  May  31,  the 
ligature  came  away,  the  discharge  gradually  lessened,  and  the 
patient  considered  herself  to  be  well.  She  came  to  London 
in  October ;  and,  although  there  was  a  very  slight  oozing  of 
pus  from  the  lowest  part  of  the  cicatrix,  she  appeared  to  be 
perfectly  well.  She  remained  well  during  the  winter  and  early 
spring,  but  in  May  1865  Mr.  Teale  wrote  to  tell  me  that  for 
some  weeks  past  there  had  been  '  at  intervals  a  considerable 
increase  of  discharge  from  the  sinus,  attended  with  uneasiness, 
but  not  with  severe  pain.  The  odour  of  the  discharge  is 
offensive — not  putrid,  but  faint  or  albuminous.  I  do  not  think 
there  is  any  lodgment  of  matter.  It  seems  to  escape  freely 
as  it  is  secreted.  Deep  in  the  left  iliac  region  is  a  general 
state  of  solidity  of  the  parts,  as  contrasted  with  the  opposite 
side.' 

It  should  be  remembered  that  although  the  ligature  which 
had  been  left  hanging  out  through  the  wound  in  the  abdominal 
wall  had  come  away  in  May  1864,  there  was  no  proof  that  the 
ligatures  tied  on  the  pedicle  after  transfixion,  and  cut  off  short, 
had  come  away.  Mr.  Teale  thought  they  might  be  present, 
and  keeping  up  irritation.  He  adds,  '  To-day  I  examined  the 
sinus  with  an  elastic  catheter,  and  at  the  depth  of  4£  inches 
encountered  a  solid  resistance.  Having  introduced  a  hollow 
elastic  tube  open  at  the  end,  I  passed  through  it  a  fine  wire 
stilet,  hooked  at  the  end,  and  tried  to  angle  for  the  retained 
ligatures,  but  without  success.  These  proceedings  were  con- 
ducted in  the  most  gentle  manner,  and  did  not  cause  the  least 
distress.'  On  May  25,  Mr.  Teale  again  wrote  :  '  She  has  been 
slightly  feverish  and  frequently  troubled  with  diarrhoea,  and  I 

F  F 


434  POST-MORTEM    EXAMINATION 

have  not  thought  it  right  to  attempt  any  mechanical  treat- 
ment. The  discharge  is  less  in  quantity,  but  I  think  it  has 
shown  a  little  faecal  tinge.' 

After  this  the  discharge  became  more  abundant  and  more 
decidedly  faecal,  varying  in  quantity  from  day  to  day.  She 
often  complained  of  a  feeling  of  painful  distension  at  the  lower 
part  of  the  abdomen.  This  was  generally  followed  by  a  gush 
of  acrid  irritating  discharge,  and  then  by  relief.  The  amount 
of  fsecal  matter  in  the  discharge  varied  considerably.  If  the 
bowels  were  not  relaxed,  there  was  little  or  none.  Latterly, 
however,  as  she  became  confined  to  bed,  she  had  frequent 
attacks  of  diarrhoea,  and  then  fluid  faeces  escaped  in  considerable 
quantity  from  the  fistula.  But  no  solid  faeces  ever  passed. 
She  gradually  became  weaker,  and  died  December  20,  1865, 
about  twenty  months  after  ovariotomy. 

I  am  indebted  to  Mr.  T.  P.  Teale  for  a  report  of  the  post- 
mortem examination.  '  The  fistulous  opening  on  the  surface 
of  the  abdomen  was  large  enough  to  admit  the  tip  of  the  little 
finger.  Within  the  abdomen  it  was  so  dilated  as  to  admit  a 
middle  finger  at  least.  On  opening  the  abdomen  we  found  the 
edge  of  the  omentum  adherent  to  the  wall  at  the  level  of  the 
wound —  a  coil  of  small  intestines  sealing  the  wound  above  the 
fistula,  which  latter  was  at  the  lower  extremity  of  the  wound. 
The  omentum  and  sub-peritoneal  tissues  were  excessively 
loaded  with  adipose  tissue.  A  small  part  of  the  small  intestine, 
the  sigmoid  flexure,  and  the  rectum  were  matted  together 
around  the  fistula  and  the  left  corner  of  the  uterus.  Close  to 
the  left  side  of  the  uterus  was  a  mass,  almost  spongy  and 
pedunculated,  which  projected  towards  the  rectum.  In  the 
centre  of  the  mass  was  a  large  suppurating  cavity  which  com- 
municated with  the  fistula  and  with  the  rectum,  by  two  large 
openings.  The  cavity  extended  for  some  distance  between  the 
uterus  and  the  rectum.  It  passed  towards  the  right  side 
behind  the  lower  part  of  the  uterus  ;  downwards  by  the  side  of 
the  rectum  ;  and  forwards  as  far  as  the  femoral  ring.  No  trace 
of  any  ligature  could  be  found.  The  right  ovary  was  healthy. 
The  liver  was  greatly  enlarged  and  much  altered  by  fatty  de- 
generation.' 

This  case,  and  others,  as  I  have  before  stated,  influenced 
me  in  favour  of  the  extra-peritoneal  treatment  of  the  pedicle. 


TETANUS  435 

The  formation  of  a  sort  of  canal  or  sinus,  by  the  adhesion 
together  of  folds  of  omentum  or  coils  of  intestine,  in  such  a 
manner  as  to  enclose  the  ligature  and  shut  it  off  from  the 
general  peritoneal  cavity,  occurs,  I  believe,  very  generally  when 
the  ends  of  the  ligature  are  not  cut  off.  If  the  patient  recover, 
one  might  expect  more  or  less  obstruction  of  intestine  to  follow 
such  adhesions;  and  at  page  427  is  a  drawing  of  a  case  where 
such  obstruction  was  actually  proved.  When  the  ends  of 
the  ligature  are  cut  off  and  the  pedicle  returned,  we  know 
that  a  similar  adhesion  of  neighbouring  intestine  sometimes 
takes  place  around  the  end  of  the  pedicle ;  and  that,  in  some 
cases,  pus  has  been  circumscribed  in  this  manner — until  at 
length  it  has  found  an  outlet,  either  through  the  abdominal 
wall,  the  vagina,  or  intestine.  The  occasional  observation  of 
cases  of  this  kind  led  me  to  believe  that  the  clamp,  or  some 
other  extra-peritoneal  method,  is  not  only  more  successful 
as  regards  the  immediate  result  of  the  operation,  but  still 
more  so  if  we  look  to  the  subsequent  health  of  the  patient. 
Patients  who  recover  after  the  extra-peritoneal  treatment  of 
the  pedicle,  as  a  rule,  soon  regain  and  maintain  perfect  health. 
So  do  many  of  those  who  recover  after  the  intra-peritoneal 
treatment.  But  some  of  them,  sooner  or  later,  suffer  from 
chronic  suppuration,  hsematocele,  or  faecal  fistula ;  or,  perhaps 
without  any  definite  local  ailment,  are  many  months  before 
they  become  strong  and  well.  This,  however,  must  be  con- 
siderably modified  by  what  has  been  observed  since  the  use  of 
antiseptics.  For  in  the  four  years  since  I  have  combined  the 
antiseptic  and  intra-peritoneal  methods  I  can  record  rapid  and 
complete  recovery  as  the  rule  ;  and  have  not  noted  one  case 
either  of  chronic  suppuration  or  faecal  fistula,  and  only  one  of 
hsematocele,  and  that  doubtful. 


TETANUS. 

If  my  own  experience  of  four  cases  in  more  than  one  thou- 
sand cases  of  completed  ovariotomy  may  be  taken  as  any  guide 
in  estimating  the  frequency  of  tetanus  after  ovariotomy,  we 
might  say  that  it  occurred  once  in  from  250  to  300  cases. 
And  there  is  more  probability  that  this  is  a  correct  estimate 
because  it   is  supported  by  the  fact  that  the   300  cases  col- 

F  F  2 


43G  REPORT   OF   CASES 

lected  by  Dr.  Lyman  with  a  view  to  ascertain  the  causes  of 
death,  furnished  exactly  one  case  of  tetanus.  Olshausen 
gives  a  table  of  twenty  cases,  and  some  particulars  of  four 
others,  of  tetanus  after  ovariotomy,  only  one  of  which,  and 
that  in  my  own  practice,  recovered ;  and  Stilling  lost  seven 
patients  from  this  complication,  out  of  a  total  of  twenty-nine 
operated  on  for  ovariotomy. 

It  is  remarkable  that,  of  the  four  cases  of  tetanus  which 
have  occurred  in  my  practice,  three  showed  themselves  very 
early,  namely,  the  9th, 'the  12th,  and  the  35th  cases,  and  I 
did  not  see  another  till  the  898th ;  a  run  of  more  than  850 
ovariotomies  without  a  sign  of  tetanus.  The  two  first  cases 
were  in  October  1859  ;  the  third  did  not  appear  till  May  1862, 
at  which  time  several  other  deaths  from  tetanus  were  registered 
in  London,  two  having  followed  the  simple  operation  of  tapping 
for  hydrocele.  From  May  1862  till  June  1878,  or  16  years,  I 
saw  not  a  single  case  of  tetanus,  nor  have  I  had  the  misfortune 
since.  Among  all  my  operations  for  the  removal  of  uterine 
tumours,  ovariotomy  twice  on  the  same  patient,  incomplete 
operations  and  exploratory  incisions,  there  were  none.  Four 
cases  of  tetanus  following  ovariotomy  are  the  only  ones 
which  I  have  to  record,  and  this  really  is  in  the  proportion 
of  one  in  about  300  for  all  gastrotomy  operations.  I  must 
certainly  have  tapped  ovarian  cysts  a  thousand  times,  have 
removed  a  great  many  tumours  of  the  breast  and  from  other 
parts  of  the  body  every  year ;  and  I  have  performed  a  large 
number  of  plastic  operations,  such  as  closing  vesico-vaginal 
fistulae  and  restoring  ruptured  perineum,  without  this  acci- 
dent, except  in  one  instance  where  it  followed  the  operation 
for  ruptured  perineum.  In  this  case,  and  in  three  out  of  the 
four  where  it  happened  after  ovariotomy,  the  patients  them- 
selves attributed  the  access  of  the  symptoms  to  a  chill.  In 
the  perineal  case  it  was  very  remarkable,  as  the  premonitory 
stiffness  and  spasms  appeared  shortly  after  the  removal  of  the 
patient's  bed  to  a  spot  immediately  beneath  an  open  ventilating 
shaft.  In  one  of  the  ovariotomy  cases  no  note  has  been  made 
as  to  chill,  but  in  the  three  others  it  was  distinctly  observed 
that  the  tetanic  symptoms  came  on  after  an  exposure  to  a 
draught  of  cold  air  when  the  patients  were  incautiously  un- 
covered.    As  preventive  treatment,  the  necessity  of  protecting 


AND    TREATMENT  437 

women  after  operation  from  currents  of  cold  air,  or  chill  in  any 
way,  is  clearly  shown.  In  regard  to  curative  treatment,  it  is 
interesting  to  state  that  the  only  case  of  the  29  collected  by 
Olshausen  which  recovered  was  that  which  I  treated  with 
woorara.  Any  one  wishing  to  follow  out  this  subject  may  refer 
to  a  paper  of  mine  read  at  the  meeting  of  the  Medico-Chirur- 
gical  Society  in  November  1859,  and  published  in  their  pro- 
ceedings. In  the  other  cases  chloroform  was  given  freely, 
woorara  was  again  tried  but  without  any  apparent  good  result, 
and  opium  was  used.  All  treatment,  however,  was  as  ineffectual 
as  it  is  generally  found  to  be,  except  in  the  very  chronic  cases. 
In  one  case  I  excised  the  remnant  of  the  exposed  pedicle  and 
a  portion  of  omentum  which  had  been  tied  and  brought  out 
through  the  wound,  hoping  that,  as  injured  nerves  in  the 
pedicle  might  be  the  origin  of  some  injurious  reflex  action, 
when  the  cause  of  the  mischief  was  taken  away,  there  would 
be  some  mitigation  of  the  symptoms.  Olshausen  attributes 
the  high  mortality  which  he  has  tabulated  partly  to  the  irri- 
tation of  hare-lip  pins,  but  the  greater  proportion  of  it  to 
insufficient  tightness  of  the  clamp,  indicated  by  secondary 
haemorrhage,  so  that  the  nerves  of  the  pedicle  were  not  so 
thoroughly  crushed  as  to  render  them  powerless  in  exciting 
marked  reflex  action.  Messrs.  Harris  and  Doran  recently 
examined  the  spinal  cord  after  the  death  of  a  woman  in  the 
Samaritan  Hospital,  and  in  their  report  to  the  Pathological 
Society  state  that  they  only  found  appearances  which  are  seen 
after  other  diseases,  such  as  exudations,  dilated  vessels,  want 
of  symmetry  and  exuberant  proliferation  in  the  central  canal ; 
and  they  conclude  that  the  clinical  symptoms  do  not  encourage 
us  in  the  expectation  of  finding  any  specific  change  in  the 
cord,  though  it  is  unquestionably  the  structure  partly,  if  not 
chiefly,  at  fault.  Here  there  was  no  apparent  local  morbid 
action,  and,  so  far  as  my  own  cases  are  concerned,  I  have  no 
reason  to  believe  that  any  pathological  condition  connected 
with  the  operation  had  anything  more  to  do  with  the  disease 
than  as  giving  the  same  predisposition  which  would  come  from 
a  common  wound. 


438  PRACTICAL   QUESTIONS    ARISING    OUT   OF 


CHAPTER   XIII. 

OVARIOTOMY   DURING   PREGNANCY 

Ovarian  tumours  may  not  only  be  mistaken  for  pregnancy 
when  they  exist  independently,  but  they  are  often  complicated 
by  its  occurrence  even  in  advanced  stages  of  their  growth.  And 
though  the  diagnosis  of  this  condition  is  generally  to  be  made 
out  by  the  usual  order  of  examination,  yet  the  complication 
may  be  revealed  only  at  the  time  of  the  operation.  Out  of 
these  circumstances  several  very  important  practical  questions 
arise. 

It  may  be  asked,  in  the  first  place,  whether  in  such  a  case 
it  would  be  necessary  to  interfere  at  all,  under  the  assumption 
that  pregnancy  and  ovarian  disease  might  go  on  together,  and 
serious  trouble  arise  only  in  a  small  percentage  of  cases.  The 
early  induction  of  premature  labour  has  also  been  advocated 
on  the  grounds  that  rupture  of  the  cyst,  or  its  gangrene  from 
rotation  of  the  pedicle,  might  occur  under  the  pressure  of 
the  enlarging  uterus,  while  relief  was  often  found  in  the 
advent  of  spontaneous  premature  labour.  Some  practitioners, 
again,  have  declared  themselves  in  favour  of  tapping  the 
ovarian  cyst,  rather  than  inducing  premature  labour,  thus 
anticipating  the  dangers  of  rupture  or  gangrene  of  the  cyst 
without  sacrificing  the  child.  And  then  comes  the  triple 
question,  in  reference  to  ovariotomy,  whether  it  should  be  per- 
formed at  all  during  the  existence  of  pregnancy ;  whether,  if 
done,  it  should  be  supplemented  by  the  Csesarean  section,  or 
Porro's  operation  ;  and,  thirdly,  whether  if,  during  ovariotomy, 
the  uterus  should  give  way  or  be  accidentally  opened,  its 
contents  should  be  cleared  out,  or  the  parts  left  to  themselves, 
or  Porro's  operation  be  performed. 

These  questions  are  of  such  vital  importance  that  we  may 
endeavour  to  arrive  at  some  general  principles  or  useful  rules 


THE   COMPLICATION   OF   OVARIAN   DISEASE   WITH   PREGNANCY    439 

of  practice   by  the  consideration  of  a  series  of  cases  in  which 
the  several  difficulties  presented  themselves. 

In  commencing  the  study  of  the  treatment  of  these  cases, 
we  naturally  examine  the  assertion  that  no  treatment  at  all  is 
called  for ;  that  ovarian  disease  and  pregnancy  may,  as  a  rule, 
be  allowed  to  progress  together  without  interference.  I  might 
support  this  doctrine  by  the  fact  that  I  knew  one  woman  who, 
during  the  slow  progress  of  an  enlarging  ovarian  cyst,  went 
through  five  pregnancies,  bore  five  living  children  without 
unusual  difficulty  ;  and  never  had  the  cyst  been  tapped,  nor  had 
labour  ever  been  prematurely  or  artificially  induced ;  and  by 
the  fact  that  in  another  case  where  I  performed  ovariotomy 
successfully  fifteen  months  after  the  birth  of  twins,  the  patient 
had  begun  to  enlarge  six  months  before  marriage,  and  had  only 
suffered  from  her  excessive  size  during  this  pregnancy ;  and  by 
the  fact  that  a  patient,  upon  whom  I  performed  ovariotomy 
with  success  in  the  fourth  month  of  pregnancy,  after  rupture 
of  the  cyst  and  peritonitis,  had  borne  six  living  children  during 
the  progress  of  the  cyst  before  its  rupture.  But  I  must  regard 
these  cases  as  exceptional,  for  I  can  only  remember  one  other 
case  where  pregnancy  complicated  with  ovarian  disease  has 
gone  on  to  its  natural  termination  in  the  birth  of  a  living 
child ;  or  where,  in  consequence  of  non-interference,  great 
suffering  has  not  arisen  during  or  after  labour,  or  very  grave 
danger  from  rupture  or  rotation  of  the  cyst ;  or  where  it  has 
not  been  necessary  to  guard  against  threatening  danger,  and 
either  to  tap  the  cyst  or  to  induce  premature  labour. 

In  the  first  three  cases,  which  I  now  proceed  to  narrate, 
death  followed  the  spontaneous  rupture  of  an  ovarian  cyst  in 
or  before  the  seventh  month  of  pregnancy. 

Case  1.— On  the  26th  of  July,  1864,  I  saw  a  lady,  29 
years  of  age,  the  wife  of  a  medical  man  and  mother  of  three 
children,  the  youngest  of  whom  was  eleven  months  old.  The 
catamenia  had  ceased  eighteen  weeks  before  my  visit,  and  the 
usual  symptoms  of  early  pregnancy  followed,  but  with  severe 
paroxysms  of  pain  in  the  right  groin  and  right  side  of  the 
abdomen.  Dr.  Ballard  had  been  consulted  on  the  13th  of 
June,  and  he  afterwards  informed  me  that  he  then  detected 
*  fulness,  with   a  hard,  irregular  tumour  partially  fluctuating 


440  CASES   OF   OVAIUAN    DISEASE 

and  somewhat  tender,  in  the  right  flank,  movable  and  dull  on 
percussion,  the  fundus  of  an  enlarged  uterus  being  palpable 
above  the  pubes,  with  resonance  between  it  and  the  tumour.' 
As  the  tumour  grew,  it  extended  across  the  hypogastrium  and 
obscured  the  enlarging  uterus,  producing  changes  in  the  physical 
signs  and  increased  sufferings,  which  led  to  different  opinions 
being  expressed  as  to  the  nature  of  the  abdominal  enlargement, 
and  to  my  being  consulted.  Considerable  doubt  having  been 
expressed  as  to  whether  a  tumour  which  reached  upwards 
about  midway  between  the  pubes  and  umbilicus  was  the 
enlarged  uterus  or  not,  I  introduced  the  sound  to  the  extent 
of  six  inches,  having  previously  considered  in  consultation 
that  if  this  proceeding  should  lead  to  abortion  the  result  would 
not  be  undesirable.  The  foetal  heart  and  placental  murmur 
not  being  audible,  doubt  was  still  felt  whether  the  enlargement 
of  the  uterus  was  due  to  pregnancy.  The  uterus  was  pushed 
a  little  over  to  the  left  side :  while  on  the  right,  not  crossing 
the  median  line,  an  elastic  tumour  extended  upwards  beneath 
the  false  ribs,  and  could  not  be  separated  by  percussion  from 
the  liver.  I  suggested  that  if  premature  labour  did  not  come 
on,  this  tumour  should  be  punctured.  I  did  not  see  the 
patient  again ;  but  I  heard  from  Dr.  Ballard  that  on  the 
11th  of  August,  a  fortnight  after  my  visit,  he  'distinctly 
felt  the  movements  of  a  child  to  the  left  of  and  below  the 
umbilicus.  The  patient  had  by  this  time  lost  flesh  consider- 
ably, but  her  pain  had  been  tolerable,  and  for  some  days  she 
was  free  from  it  altogether.  On  the  26th  of  September  it 
returned  with  great  severity,  with  evidence  of  peritonitis.  On 
the  28th  she  was  believed  to  be  in  labour,  and  was  seen  by 
Dr.  Oldham  and  Dr.  Barnes.  The  membranes  protruding, 
they  were  ruptured,  and  some  hours  afterwards  a  female  child 
was  born,  which  lived  twenty-four  hours.  The  symptoms  of 
peritonitis  continued,  and  the  patient  died  four  days  after  the 
delivery.' 

After  death  Dr.  Ballard  found  a  very  large  cyst  of  the  right 
ovary,  occupying  the  whole  of  the  right  side  of  the  abdomen, 
and  extending  four  inches  to  the  left  of  the  median  line.  It 
was  flaccid,  as  if  partially  emptied,  and  a  large  quantity  of 
bloody  serous  fluid  lay  in  the  lower  part  of  the  abdominal 
cavity.     The  pedicle,  an  inch  and  a  half  long,  was  twisted  into 


COMPLICATED   WITH   PREGNANCY  441 

a  sort  of  rope,  and  the  walls  of  the  cyst  were  infiltrated  with 
blood.  Within  the  cyst  there  was  much  bloody  serum  with 
several  very  firm  clots.  Some  of  the  contents  of  the  cyst  had 
evidently  escaped  through  an  opening  in  a  very  thin  part  of 
the  cyst  wall  posteriorly,  and  had,  no  doubt,  caused  the  peri- 
tonitis which  proved  fatal. 

Case  2. — In  May  1868  I  went  to  Stafford  to  see,  in 
consultation  with  Dr.  Day,  a  lady  who  was  in  the  fifth 
month  of  pregnancy  and  was  also  suffering  from  an  ovarian 
tumour,  which  had  been  discovered  by  her  husband  on  the 
night  of  marriage  in  October  1866.  She  was  twenty-four 
years  of  age,  had  long  suffered  from  hysterical  attacks,  but 
nothing  had  led  to  any  examination  of  the  abdomen  until 
the  movable  tumour  in  the  right  iliac  region  was  dis- 
covered, which  she  appeared  to  be  quite  ignorant  of,  and 
said  she  had  never  noticed.  It  was  about  the  size  of  a  very 
large  orange.  Dr.  Oldham,  who  saw  it  a  few  days  afterwards, 
considered  it  to  be  an  ovarian  tumour.  From  the  time  of 
marriage,  the  tumour  evidently  but  slowly  increased  in  size, 
and  was  the  seat  of  frequent  darting  pains.  Eight  months 
after  marriage  she  became  pregnant,  miscarried  six  weeks  after 
conception,  and  recovered  without  any  unfavourable  symptom. 
From  this  time  till  the  end  of  1867  there  was  no  decided 
increase  nor  other  change  in  the  tumour.  Then  a  second 
pregnancy  occurred.  She  began  to  suffer  from  intense  pain 
in  the  tumour,  and  became  restless  and  desponding.  It  was 
in  the  fifth  month  of  this  second  pregnancy  that  I  saw  her, 
and  found  an  ovarian  cyst  as  large  as  an  adult  head  above  and 
to  the  right  of  the  uterus.  At  that  time  there  was  no  very 
great  suffering,  but  I  advised  that  the  cyst  should  be  tapped 
if  relief  was  called  for  by  any  increased  distress.  At  about 
the  sixth  month  premature  labour  came  on  spontaneously,  and 
she  was  delivered  of  a  dead  child.  From  the  period  of  her 
delivery  many  of  her  symptoms  subsided ;  she  slept  well, 
was  cheerful,  and  the  tumour  was  less  painful.  But  after 
about  a  week  she  began  to  complain  of  more  pain  in  the 
tumour,  and  it  increased  rapidly  in  size.  Her  hysterical 
symptoms  became  aggravated  to  a  degree  almost  amounting 
to  mania.  Dr.  Day  informed  mc  that  'the  tumour,  all  hough 
increasing    rapidly   in    size    and    becoming    very   tense    and 


442  CASES    OF    OVARIAN    DISEASE 

hard,  was  not  so  large  as  to  render  the  abdominal  walls 
very  tense,  or  to  press  upon  other  organs  so  as  to  interfere 
with  the  performance  of  their  functions.  The  pulse,  which 
had  fallen  in  frequency  after  the  premature  delivery,  again 
became  weak,  and  rose  to  120.  This  state  continued  without 
alteration  for  about  a  week  or  ten  days.  One  morning, 
after  turning  somewhat  suddenly  in  bed,  she  cried  out  that 
something  had  broken  inside,  and  died  almost  instantly. 
No  post-mortem  was  made,  but  the  abdomen  was  found 
to  be  perfectly  flaccid.  Not  a  trace  of  the  tumour  could  b< 
felt.' 

Case  3. — On  the  16th  of  January,  1869,  I  met  Dr.  Finch, 
of  Blackheath,  and  Dr.  Furley,  of  Mailing,  in  consultation 
upon  a  lady,  24  years  of  age,  who  had  been  married  about, 
nine  months.  Between  two  and  three  months  after  marriage 
the  catamenia  ceased,  she  increased  in  size,  and  considered 
herself  pregnant.  After  a  long  drive,  which  shook  her  very 
much,  on  the  20th  qf  November,  she  was  seized  at  night  with 
intense  pain.  Dr.  Finch  was  sent  for  and  told  that  abortion 
was  threatening,  but  he  found  her  suffering  from  a  severe 
attack  of  acute  peritonitis,  the  abdomen  being  greatly  distended, 
and  containing  a  tumour  the  size  of  the  uterus  at  nearly  the 
full  period.  There  was  no  injection  of  the  mammary  areolae, 
nor  any  other  sign  of  pregnancy.  The  next  day  she  was  seen 
by  a  distinguished  physician-accoucheur,  who  could  not  satisfy 
himself  as  to  the  existence  of  pregnancy.  The  acute  symp- 
toms subsided,  and  on  the  23rd  of  November  the  physician 
just  alluded  to  and  another  eminent  physician -accoucheur, 
who  had  seen  the  lady  some  years  before,  met  Dr.  Pinch  in 
consultation. 

This  gentleman,  although  admitting  some  doubt,  expressed 
himself  pretty  confidently  as  to  pregnancy,  on  account  of  the 
soft  cushiony  state  of  the  cervix  uteri,  seldom  found  in  young 
newly  married  women  when  not  pregnant.  He  said  that  he 
had  seen  the  patient  in  1865,  who  had  then  told  him  that,  five 
years  before  that  time,  after  a  chill  when  dancing,  she  had 
felt  pains  which  had  been  followed  by  enlargement  in  the 
left  groin.  A  tumour,  irregularly  nodular,  not  fluctuating, 
and  movable,  was  felt  in  1865,  reaching  nearly  to  the  um- 
bilicus in  the  centre,  and  nearly  up  to  the  false  ribs  on  the 


COMPLICATED   WITH    PREGNANCY  443 

left  side.  He  then  regarded  the  tumour  as  probably  ovarian, 
and  considered  that  it  had  not  much  enlarged  since,  but  had 
become  comjDlicated  with  pregnancy.  After  this  consultation 
the  health  improved,  and,  notwithstanding  some  slight  symp- 
toms of  peritonitis,  on  several  occasions  she  was  able  to  walk 
about  her  room.  The  abdomen  gradually  increased  in  size, 
and  at  my  first  and  only  visit  I  could  distinctly  trace  the 
boundaries  of  three  tumours,  or  separable  portions  of  one 
tumour — one  central,  extending  upwards  half  way  from  the 
pubes  to  the  umbilicus ;  one  on  the  left  side,  extending 
into  the  left  flank  and  reaching  about  an  inch  above  the 
umbilicus ;  and  one  on  the  right  side,  extending  nearly  to  the 
false  ribs.  The  central  tumour  felt  exactly  like  a  pregnant 
uterus.  The  tumours  to  the  right  and  left  were  not  fluc- 
tuating, but  they  felt  softer  than  fibroid  tumours  of  the  uterus 
usually  do.  The  cervix  uteri  was  shortened  and  softened, 
strongly  supporting  the  belief  in  the  pregnancy.  But  no 
sound  of  foetal  heart  nor  placental  murmur  could  be  detected. 
To  the  left  of  the  cervix,  projecting  towards  the  bladder,  a 
hard  nodulated  tumour,  as  large  as  three  or  four  walnuts, 
closely  connected  with  the  body  of  the  uterus,  could  be  felt. 
This,  I  felt  sure,  was  a  fibroid  outgrowth  from  the  uterus, 
and  I  made  a  diagram  illustrating  my  diagnosis  of  preg- 
nancy with  a  small  hard  fibroid  outgrowth  from  the  body  of 
the  uterus,  and  two  softer  tumours,  which  might  be  either 
ovarian  tumours  or  soft  uterine  fibroids ;  and  I  advised  that 
the  physicians  who  had  seen  her  six  weeks  before  should  see 
her  again,  and  consult  as  to  the  propriety  of  inducing 
premature  labour,  as  I  did  not  thing  that  tapping  could 
lead  to  any  considerable  diminution  in  the  size  of  either  of 
the  tumours. 

A  fortnight  after  this  advice  was  given,  Dr.  Finch  distinctly 
heard  the  foetal  heart.  This  was  on  January  29.  On  February 
8,  at  four  in  the  morning,  after  a  quiet  day  on  the  7th,  free 
from  much  pain,  she  awoke  after  three  hours'  sleep,  complained 
of  pain,  asked  for  fomentations  of  hot  water,  then  coughed, 
fell  back,  and  suddenly  died.  Dr.  Finch  adds,  '  I  presume, 
from  the  bursting  of  a  large  cyst,  but  I  had  no  opportunity  of 
making  a  post-mortem  examination.' 

Cases  4  and  5. — It  is  unnecessary  to  detail  the  particulate 


444  TAPPING   IN    OVARIAN    DISEASE   WITH    PREGNANCY 

of  these  cases,  the  simple  facts  being  that  two  patients  who 
were  pregnant  had  also  large  ovarian  cysts,  which  I  thought 
should  be  emptied  by  tapping,  but  my  advice  was  not  followed. 
Both  women  suffered  excessively  from  distension,  had  lingering 
labours  and  still-born  children.  In  both  ovariotomy  was  per- 
formed a  few  weeks  after  delivery,  successfully  in  one,  with  a 
fatal  result  in  the  other. 

I  have  also  notes  of  five  cases  of  patients  whom  I  have 
tapped  during  pregnancy,  one  of  them  three  times,  one  twice, 
and  three  once.  In  all  these  women  great  relief  was  afforded 
by  the  tapping,  no  ill  effect  of  any  kind  was  observed  to  follow 
it,  and  in  all  cases  the  children  were  born  alive  after  labours  of 
moderate  duration.  One  of  these  cases  is  of  sufficient  interest 
to  deserve  a  short  report. 

Case  6. — In  November  1865  I  performed  ovariotomy  with 
a  successful  result  upon  a  married  woman,  forty  years  of  age, 
four  months  after  the  birth  of  a  living  child  at  the  full  term 
of  pregnancy.  I  had  tapped  this  woman  two  months  before 
her  delivery.  She  was  sent  to  me  by  Mr.  Ward,  of  Newark, 
in  May  1865.  He  had  tapped  her  twice,  removing  nearly  four 
gallons  of  fluid  each  time.  The  first  tapping  was  in  April 
1864,  the  second  in  February  1865.  When  I  saw  her  first 
she  had  been  married  three  years,  and  had  not  had  a  child. 
The  catamenia  became  scanty  about  the  time  of  her  marriage, 
and  'got  less  and  less  till  they  left  herein  November  1864. 
The  abdomen  was  greatly  distended,  and  nothing  could  be 
detected  except  a  very  large  ovarian  cyst,  nor  could  the  patient 
believe  that  she  was  pregnant.  But  the  cervix  uteri  was  found 
to  be  short  and  velvety,  and  ballottement  was  very  distinct. 
The  mammary  areolae  were  injected,  the  corpuscles  well  deve- 
loped, and  a  little  colostrum  was  squeezed  from  the  nipples. 
As  the  suffering  from  distension  was  very  great  and  immediate 
relief  necessary,  I  tapped  on  May  13,  and  removed  eighteen 
pints  of  fluid.  The  enlarged  uterus  was  then  felt  nearly  up  to 
the  umbilicus,  the  collapsed  cyst  to  the  left,  and  the  foetal 
heart  was  heard  below  and  to  the  left  of  the  umbilicus.  Imme- 
diate relief  followed  the  tapping.  A  healthy  child  was  born 
on  July  20,  at  the  full  term  of  pregnancy.  The  patient  was 
too  weak  to  nurse  it.  The  cyst  refilled,  and  I  removed  it  in 
•the  Samaritan   Hospital  on  November  20,  1865.    There  were 


OVARIOTOMY    AND    CESAREAN    SECTION  445 

very  extensive  adhesions,  but  the  patient  made  an  excellent 
recovery,  and  had  another  child  in  September  1867.  I  heard 
from  her  in  November  1881  as  being  quite  well. 

Case  139. — As  I  published  a  very  full  report  of  this  case  in 
the  'Medical  Times  and  Gazette' of  September  30,  1865,1 
need  not  do  more  now  than  point  out  its  bearing  upon  the 
question  of  the  performance  of  ovariotomy  during  pregnancy. 
In  this  case  I  entirely  overlooked  the  coexistence  of  pregnancy 
with  ovarian  disease,  and  after  the  removal  of  an  adherent 
multilocular  cyst  of  the  left  ovary,  weighing  about  twenty-eight 
pounds,  I  felt  what  I  thought  was  a  cyst  of  the  right  ovary, 
tapped  it,  and  then  found  that  it  was  the  gravid  uterus.  As 
this  stage  of  the  operation  is  of  some  importance  in  the  history 
of  the  Csesarean  section,  being,  I  believe,  the  first  case  in  which 
the  opening  in  the  uterine  wall  was  closed  by  sutures,  I 
quote  the  following  passage  from  the  report  published  at  the 
time  : — 

'  Some  two  or  three  pints  of  bloody  fluid  having  escaped 
through  the  canula,  the  tumour  became  much  less  tense ;  and 
on  bringing  it  up  to  the  surface  I  saw  the  Fallopian  tube 
passing  from  its  upper  part  towards  the  left  side,  and  knew  at 
once  that  I  had  punctured  the  uterus.  On  withdrawing  the 
canula,  a  soft,  spongy,  bleeding  mass  protruded,  and  on  putting 
in  my  finger  to  push  this  back  and  examine  the  uterine  cavity, 
the  anterior  wall  of  the  uterus — which  was  very  soft  and  friable, 
as  if  it  had  undergone  fatty-degeneration — gave  way  along  the 
middle  line  from  the  puncture  (which  was  near  the  fundus)  for 
an  extent  of  from  three  to  four  inches  down  the  body  towards 
the  neck.  With  very  slight  pressure  a  quantity  of  liquor  amnii 
and  a  foetus  of  about  five  months  escaped.  I  then  easily  peeled 
off  the  placenta  from  the  inner  surface  of  the  uterus.  The 
organ  did  not  contract,  and  there  was  free  bleeding  from  three 
vessels  close  beneath  the  peritoneum  at  the  lower  angle  of  the 
rupture  in  the  uterus.  These  vessels  were  secured  by  three 
silk  ligatures.  Oozing  still  going  on  from  the  surface  where 
the  placenta  had  been  attached,  I  made  a  free  opening  into 
the  vagina  by  passing  my  finger  from  above  through  the  cervix 
;iT)d  os,  and  then  put  a  piece  of  ice  into  the  uterus,  and  held  it 
within  by  firmly  grasping  the  organ,  which  then  contracted. 
I   then  broughl    the  peritoneal  edges  of  the  tear  in  the  uterus 


446  PRACTICAL    QUESTIONS    AND    CONCLUSIONS 

together  by  an  uninterrupted  suture  of  fine  silk,  one  long  end 
of  which  I  had  previously  passed  into  the  uterine  cavity,  and 
out  through  the  os  into  the  vagina.  By  seven  or  eight  points 
the  edges  were  brought  accurately  together,  and  the  other 
end  of  the  silk  was  brought  out  through  the  opening  in  the 
abdominal  wall,  with  the  ends  of  the  three  ligatures  on  the 
vessels  in  the  uterine  wall,  close  to  the  pedicle,  and  all  were  tied 
to  the  clamp.' 

Any  one  interested  in  the  progress  of  this  patient  after  this 
complicated  operation  may  find  a  very  full  report  in  the  Journal 
to  which  I  have  referred.  All  I  need  say  now  is  that  the 
patient  completely  recovered.  She  went  to  the  Convalescent 
Hospital  at  Eastbourne  thirty-three  days  after  operation,  and  I 
have  seen  her  several  times  since  in  excellent  health,  the  last 
time  in  1880.     She  reports  herself  well  in  1881. 

The  interest  of  this  case  in  relation  to  the  subject  under 
notice  is  in  its  bearing  on  the  question,  '  What  should  be  done 
when  a  pregnant  uterus  is  discovered  during  some  stage  of 
ovariotomy  ? '  My  answer  would  be,  '  Let  it  alone.'  But  in  a 
case  of  Dr.  Atlee's  in  1850,  ovariotomy  performed  in  the  second 
month  of  pregnancy  was  '  followed  by  such  great  irritability  of 
stomach,  in  consequence  of  the  state  of  pregnancy,  that  she 
could  not  be  nourished,  and  she  died,  thirty  days  after,  of  star- 
vation.' And  in  a  case  by  Mr.  Burd,  of  Shrewsbury,  in  1847, 
of  ovariotomy  performed  between  the  third  and  fourth  months 
of  pregnancy,  abortion  took  place  two  days  after  operation,  and 
was  followed  by  alarming  symptons,  lasting  several  days.  Still 
the  patient  recovered.  So  Dr.  Marion  Sims  performed  ovari- 
otomy in  the  third  month  of  pregnancy,  and  did  not  detect 
pregnancy  until  the  ovarian  tumour  had  been  removed.  The 
patient  recovered  well,  went  the  full  term,  and  was  safely 
delivered  of  a  fine  child. 

Supposing  the  operator  has  penetrated  the  uterus,  if  any 
conclusion  can  be  drawn  from  the  case  in  which  I  made  this 
mistake  and  emptied  the  uterus,  and  two  other  cases  in  which 
the  same  mistake  was  made  by  other  surgeons,  who  did  not 
empty  the  uterus,  but  closed  the  puncture  in  its  wall  by  wire 
sutures,  both  patients  having  died  after  aborting,  while  mine 
recovered,  it  would  appear  to  be  the  safer  practice  to  empty 
the  uterus,  and  either  to  close  the  opening  in  the  uterine  wall 


OVARIOTOMY  AT  THE  FOURTH  MONTH  OF  PREGNANCY   447 

by  suture,  or  to  perform  supra-vaginal  amputation  of  the  uterus 
as  advised  and  practised  by  Porro  first,  and  afterwards  by  other 
Continental  surgeons. 

I  now  proceed  to  relate  four  other  cases  occurring  in  my  first 
series  of  five  hundred,  in  one  of  which  ovariotomy  was  performed 
at  the  fourth  month  of  pregnancy,  after  rupture  of  the  cyst  and 
peritonitis  ;  in  the  second,  third,  and  fourth  the  operation  was  a 
matter  of  election  to  avoid  other  dangers.  The  result  was  suc- 
cessful in  all  of  them,  the  mothers  being  saved,  three  of  them 
giving  birth  to  living  children  after  natural  labours  at  the  full 
period  of  pregnancy,  and  the  fourth  having  recovered  well  after 
a  rapid  labour  eleven  weeks  after  ovariotomy. 

Case  330. — The  wife  of  an  hotel-keeper,  thirty-six  years  of 
age,  mother  of  eight  children,  first  consulted  Mr.  Bateman 
on  July  23,  1869.  About  a  fortnight  before  this  an  abdominal 
tumour,  which  had  been  slowly  increasing  after  the  birth  of 
twins  sixteen  years  before,  and  had  not  prevented  the  birth  of 
six  other  children,  had  suddenly  and  rapidly  increased  in  size 
after  an  attack  of  severe  abdominal  pain  and  tenderness  with 
sickness  and  fever.  When  Mr.  Bateman  was  called  in  he  con- 
sidered '  the  case  was  full  of  peril,  for,  although  the  abdominal 
tenderness  was  subsiding,  the  effusion  was  increasing.  There 
was  considerable  difficulty  of  breathing  on  lying  down,  and 
great  restlessness,  with  scanty  and  deep-coloured  urine,  abound- 
ing in  lithates.'  Mr.  Bateman's  diagnosis  was  '  ovarian  tumour 
on  the  right  side,  ascites,  pregnancy  of  about  three  months' 
duration,  and  extensive  recto-vaginal  protrusion.'  On  August 
13,  I  saw  the  patient  with  Mr.  Bateman  by  his  desire,  and 
entirely  concurred  in  his  diagnosis  as  to  the  presence  of  an 
ovarian  tumour  with  free  fluid  surrounding  it  in  the  peritoneal 
cavity,  and  depressing  the  recto-vaginal  pouch,  and  in  the 
existence  of  pregnancy  about  the  commencement  of  the  fourth 
month.  '  We  also  came  to  the  conclusion  '  (I  now  quote  from 
Mr.  Bateman)  '  that  the  fluid  in  the  peritoneal  cavity  was 
ovarian  fluid,  the  sudden  attack  of  pain  when  I  was  first  called 
in  having  been  caused,  in  all  probability,  by  the  rupture  of 
part  of  the  wall  of  a  multilocular  cyst,  and  the  escape  of  the 
contents  of  a  large  cyst.  Pain,  tenderness,  raised  temperature, 
rapid  pulse,  dry  tongue,  and  sickness,  all  pointed  to  diffused 
peritonitis,  and   a  condition   requiring  immediate  relief.'     On 


448       OVARIOTOMY    AT    THE    THIRD    MONTH    OF    PREGNANCY 

the  following  day  I  performed  ovariotomy,  most  ably  assisted 
by  Mr.  Bateman,  by  Dr.  Jagielski,  and  by  Professor  Neuge- 
bauer,  of  Warsaw,  Dr.  Junker  administering  bichloride  of 
methylene  with  his  usual  care  and  success.  Our  diagnosis  was 
completely  verified.  There  was  general  injection  of  the  peri- 
toneum, but  no  recent  lymph.  The  only  adhesion  was  to 
omentum.  The  tumour,  with  its  contents  and  the  fluid  sur- 
rounding it,  weighed  altogether  thirty-seven  pounds.  I  was 
extremely  careful  to  cleanse  the  peritoneal  cavity  completely 
from  all  ovarian  fluid  by  repeated  sponging  before  closing  the 
wound. 

The  patient  recovered  perfectly  well,  went  from  London  to 
Eamsgate  twenty-eight  days  after  the  operation,  and  arrived 
there  with  very  little  fatigue.  She  returned  in  excellent 
health,  and  pregnancy  went  on  without  any  unusual  symptom. 

In  the  'Lancet 'of  March  19,  1870,  Mr.  Bateman  states 
that  this  patient  was  safely  delivered  of  a  living  child  on 
February  18,  after  a  natural  labour,  and  went  on  well  after- 
wards. But  she  died  in  1871  of  malignant  disease  of  the 
uterus. 

Case  399. — In  this  case  I  was  acting  with  Mr.  Groddard,  of 
Highbury,  and  I  feel  much  satisfaction  in  reprinting  his  report 
to  the  Obstetrical  Society. 

'  In  August  1869  I  attended  a  lady,  twenty-eight  years  of 
age,  in  her  fifth  confinement.  She  was  married  in  1863,  and 
her  eldest  child  was  born  in  the  same  year.  She  had  one 
abortion  in  1868.  After  the  delivery  in  1869  some  fulness  of 
the  abdomen,  not  observed  after  previous  confinements,  was 
noticed,  and  the  increase  in  size  went  on  gradually.  Occa- 
sional pain  in  the  left  groin  and  hip  had  been  felt  for  the 
previous  four  years.  In  August  1870  Mr.  Spencer  Wells  saw 
her  with  me,  and  confirmed  my  opinion  that  an  ovarian  cyst  of 
considerable  size  was  present ;  but  as  the  general  health  was 
good,  and  there  was  no  very  urgent  symptom,  we  agreed  to 
defer  any  consideration  of  surgical  treatment.  On  October  17, 
1870,  a  regular  catamenial  period  ceased,  and  symptoms  of  preg- 
nancy began  within  a  fortnight — sickness  and  frequent  micturi- 
tion, as  in  previous  pregnancies.  At  the  next  period  in  Novem- 
ber there  were  no  signs  of  menstruation,  and  increase  in  size 
continued.     On   December    12,  a  second   period  was  due  and 


OVARIOTOMY   AT   THE   SECOND   MONTH   OF   PREGNANCY       449 

passed  over,  nausea  and  discomfort  increasing  with  the  increasing 
size  of  the  abdomen. 

*  Taking  all  the  circumstances  of  the  case  into  careful  con- 
sideration with  Mr.  Spencer  Wells,  it  was  agreed  that  he 
should  perform  ovariotomy  on  December  20,  1870,  and  he  did 
so,  assisted  by  Dr.  Legouest,  of  Paris,  by  Dr.  Bantock,  by  my 
friend  Dr.  Shepherd,  and  by  my  father  and  myself.  Complete 
anaesthesia  was  maintained  by  Dr.  Day  with  chloro-methyl. 
An  incision  five  inches  long  between  the  umbilicus  and  pubes 
exposed  a  non-adherent  ovarian  cyst,  which  was  tapped,  and 
one  large  cavity  was  emptied.  The  principal  cyst  was  then 
opened,  cysts  broken  up,  and  the  whole  tumour  was  drawn  out 
without  any  of  the  contents  escaping  into  the  peritoneal  cavity. 
A  long  narrow  pedicle  on  the  left  side  was  secured  in  a  small 
clamp,  which  was  fixed  outside  the  abdominal  wall.  Scarcely 
any  blood  was  lost.  The  right  ovary  was  healthy.  The  uterus 
appeared  to  be  as  large  as  a  cocoa-nut,  and  Mr.  Wells  said  it 
felt  like  a  thin  cyst,  larger  than  he  should  have  expected  at  the 
commencement  of  the  third  month  of  pregnancy.  The  wound 
was  united  by  silk  sutures  passed  through  the  whole  thickness 
of  the  abdominal  wall.  The  fluid  removed  measured  eleven 
and  a  half  pints  ;  the  weight  of  the  cyst  and  solid  matter  was 
three  and  a  quarter  pounds.     Total,  about  fifteen  pounds. 

1 1  have  little  to  say  of  the  progress  after  the  operation  except 
that  recovery  was  rapid  and  complete.  The  clamp  was  removed, 
and  the  bowels  acted  on  the  eighth  day.  Pregnancy  went  on 
quite  unaffected  by  the  operation,  and  a  healthy  child  was  born 
after  a  natural  labour  on  July  29,  1871.  The  lady  has  nursed 
her  child,  and  has  gone  on  quite  as  well  as  after  any  previous 
confinement.' 

This  lady  is,  in  1881,  in  good  health,  and,  besides  the  child 
born  seven  months  after  the  operation,  has  had  three  other  fine 
strong  children,  born  in  1873,  1876,  and  1878. 

Case  419. — A  married  lady,  thirty-eight  years  of  age,  mother 
of  five  children,  and  whose  own  mother  had  died  of  dropsy  and 
some  sort  of  abdominal  tumour,  was  introduced  to  me  in  April 
1871  by  Dr.  Eoss.  Eighteen  years  ago,  before  her  marriage, 
he  had  discovered  the  existence  of  a  tumour,  and  observing  its 
progress,  found  at  each  delivery  that  it  had  diminished  during 
tlir  pregnancy.     All  the  deliveries  were  natural  except  one, and 

<;  <; 


450  REMOVAL    OF    OVARIAN    FIBROID 

in  that  Dr.  Eoss  turned.  Soon  after  the  birth  of  each  child 
the  tumour  began  again  to  increase,  but  never  so  much  as 
within  the  last  six  months,  the  youngest  child  being  eight 
months  old.  My  diagnosis  was,  ovarian  cyst,  probably  der- 
moid, uterus  free,  early  pregnancy  ;  and  on  May  4, 1  performed 
ovariotomy. 

An  incision  of  five  inches  midway  between  the  umbilicus 
and  symphysis  pubis  exposed  a  free  cyst,  which  was  tapped. 
The  tube  was  immediately  plugged,  no  fluid  escaping ;  and 
on  removing  it,  and  a  mass  of  hair  and  fat,  a  quantity  of  fluid 
gushed  away,  and  a  cyst  was  drawn  out,  with  a  coil  of  intestine, 
and  large  shreds  of  adhering  omentum  (very  vascular).  On 
separating  the  omentum  and  intestine,  I  found  that  there  was 
no  pedicle,  the  blood  supply  of  the  cyst  having  been  kept  up 
by  the  omental  vessels,  and  some  large  vessels  near  the  csecal 
appendix,  where  the  intestine  appeared  thick  and  contracted. 
Several  vessels  and  shreds  of  omentum  were  tied  and  returned 
with  the  ligatures  cut  off  short.  The  left  ovary  was  three  times 
its  natural  size,  with  large  vesicles  and  opaque  spots  on  their 
coats.  I  decided  not  to  remove  it.  The  uterus  was  large  and 
cyst-like,  and  at  the  second  month  of  pregnancy.  The  wound 
Avas  closed  with  sutures. 

The  solid  part  of  the  cyst  weighed  about  two  pounds,  and  it 
contained  as  much  as  thirty-two  pints  of  fluid.  A  large  quan- 
tity of  loose  hair,  with  fatty  matter,  which  became  solid  on 
cooling,  was  removed  from  the  cyst.  Part  of  the  cyst  wall  was 
to  the  naked  eye  exactly  like  skin,  and  elsewhere  it  was  inlaid 
with  small  bony  plates.  The  recovery  was  uninterrupted,  and 
in  the  month  of  December  Dr.  Eoss  wrote  to  me  saying  that 
the  patient  was  delivered  of  a  fine  female  child,  after  a  labour 
of  about  thirteen  hours.  She  went  on  perfectly  well,  and  was 
in  good  health  in  May  1872,  but  in  the  summer  of  1881  was 
very  ill  with  pulmonary  disease,  and  had  also  an  abdominal 
tumour  of  doubtful  nature. 

Case  476. — A  married  woman,  twenty-nine  years  of  age, 
mother  of  one  child,  was  sent  to  me  by  Dr.  Moore,  of  Ipswich, 
early  in  the  year  1872,  with  tumour  in  the  right  side,  recog- 
nized as  ovarian.  She  was  tolerably  healthy,  fresh-looking,  but 
thin.  The  skin  of  the  abdomen  was  tense  and  glistening,  the 
linere   albicantes  well  marked.     There  was  tenderness  on  the 


DURING    PREGNANCY  451 

right  side,  with  distinct  fluctuation,  but  no  crepitus ;  the 
sounds  on  percussion,  clear  superiorly,  and  changing  with  the 
position ;  in  the  lumbar  region  dull  when  the  patient  was  on 
her  back,  clear  when  on  her  side.  The  uterus  was  in  its  natural 
position,  cervix  movable  and  soft,  the  os  patulous.  The  cata- 
menia  had  ceased  for  three  months,  having  previously  been 
regular  and  natural.  The  urine  was  clear,  acid,  not  albuminous, 
but  loaded  with  lithic  acid.  The  general  health  was  not  much 
affected;  pulse  100;  sounds  of  the  heart  normal;  and  no 
special  hereditary  tendency  to  disease. 

She  first  noticed  the  enlargement  twelve  months  before, 
and  attributed  it  to  pregnancy ;  but  from  the  recurrence  of  the 
menses  she  became  doubtful,  and  at  the  end  of  eight  months 
was  no  larger  than  at  the  third.  The  tumour  was  at  first  felt 
more  in  the  right  side,  and  caused  neither  pain  nor  tenderness, 
nor  any  other  particular  symptoms. 

Within  the  last  month  she  had  increased  rapidly,  and, 
though  pregnancy  of  the  fourth  month  was  discovered,  the 
body  was  so  tense  on  admission  to  the  Samaritan  Hospital 
that  she  was  tapped  with  lancet  and  canula,  and  several  pints 
of  fluid  removed  from  the  peritoneal  cavity.  After  tapping,  a 
small,  hard,  movable  tumour  could  be  felt  in  the  right  iliac 
region,  which  I  supposed  to  be  the  solid  part  of  a  multilocular 
tumour  which  had  burst.  The  size  of  the  uterus,  softness  of 
the  cervix,  and  absence  of  the  catamenia  for  three  months 
made  pregnancy  almost  certain. 

On  March  13,  I  performed  ovariotomy,  making  an  incision 
of  five  inches  midway  between  the  umbilicus  and  symphysis 
pubis.  About  five  pints  of  clear  fluid  escaped  from  the  peri- 
toneal cavity,  and  I  felt  the  large  uterus  just  like  a  tense  thin 
cyst.  To  its  right  and  above  was  a  hard  tumour,  held  up  by 
omentum  which  adhered  to  it,  and  having  the  right  Fallopian 
tube  only  separated  from  it  by  the  broad  ligament.  I  trans- 
fixed the  ligament  by  a  needle  carrying  strong  silk.  A  large 
vein  which  was  punctured  bled  freely,  but  on  tightening  the 
silk,  and  tying  the  ligament,  bleeding  stopped.  I  cut  away  the 
tumour,  leaving  the  Fallopian  tube  untouched,  and  cut  off  the 
ends  of  the  ligatures  short.  Short  ligatures  were  used.  I  did 
not  feel  either  ovary ;  the  uterus  being  so  large  and  tense,  I 
was  anxious  not  to  disturb  it.     On  the  fifth  day  the  wound  was 

a  a  2 


452  OTHER   CASES   OF   OVARIOTOMY 

healed,  and  the  stitches  were  removed.  The  patient  recovered 
without  any  symptom  of  abortion,  was  delivered  on  May  27  of  a 
small  child,  after  a  rapid  labour,  at  the  sixth  month  of  preg- 
nancy, and  did  well.  She  has  since  given  birth  to  a  girl  at  the 
full  time,  1873,  who  is  still  living.  The  mother  reports  her- 
self well  in  1881. 

The  tumour  was  a  nearly  solid  mass  of  white  fibrous  tissue, 
infiltrated  in  places  with  a  thick  transparent  fluid,  which  had 
here  and  there  collected  in  the  distended  areolae.  But  towards 
the  upper  part  there  was  a  large  irregular  cavity  divided  by  im- 
perfect septa,  lined  with  smooth  membrane,  and  nearly  filled 
with  blood  clot,  partially  organised.  The  pedicle  was  a  small 
double  layer  of  peritoneum,  about  an  inch  and  a  half  long,  and 
a  quarter  of  an  inch  wide,  enclosing  a  few  vessels  and  some 
areolar  tissue.  The  tumour  measured  in  its  long  diameter  six 
inches  and  a  half,  and  in  its  short  diameter  three  inches  and  a 
half.  It  is  referred  to  in  the  section  on  Fibrous  Tumour  of  the 
Ovary. 

In  the  second  series  of  500  cases  of  ovariotomy,  I  per- 
formed the  operation  during  pregnancy  five  times — making  ten 
cases  in  the  1,000.  The  following  are  brief  notices  of  the  five 
cases  which  occurred  in  the  second  500. 

Case  507. — Was  a  married  woman,  thirty-two  years  of  age, 
and  mother  of  seven  children,  who  came  into  the  hospital  on 
account  of  her  great  suffering.  Tapping  only  brought  away  a 
few  ounces  of  thick  colloid  fluid,  and  as  it  gave  no  relief,  ovari- 
otomy was  done  three  days  afterwards.  Pregnancy  was  not  sus- 
pected, but  the  incision  disclosed  a  large  uterus  below  and  to 
the  left  side.  With  it  was  a  big  multilocular  cyst,  weighing 
twenty- six  pounds,  which  had  to  be  opened  and  broken  down 
as  the  contents  were  too  thick  to  pass  through  the  trocar.  The 
pedicle  was  first  fastened  in  a  clamp.  This  caused  too  much 
dragging  on  the  parts  and  was  replaced  by  ligature  about  an 
inch  away  from  the  right  side  of  the  uterus.  Four  pieces  of 
adhering  omentum  had  to  be  tied  and  were  returned.  The 
left  ovary  was  found  applied  to  the  side  of  the  uterus,  which 
was  as  large  as  at  the  sixth  month  of  pregnancy.  Labour  pains 
came  on  the  next  morning,  the  membranes  were  punctured, 
and  in  about  ten  minutes  a  living  child  was  expelled.  The 
temperature  never  rose  to  more  than  100°,  and  on  the  ninth 


DURING  PREGNANCY  453 

day  the  notes  end.  The  patient  recovered  rapidly,  and  in 
December  1873  presented  herself  at  the  hospital  with  another 
healthy  child.  This  has  since  been  followed  by  another  birth 
and  a  third  pregnancy. 

Case  752. — This  case  need  not  be  recorded  at  all  fully,  as 
Dr.  Kidd  of  Dublin  has  published  a  circumstantial  account  of 
it.  It  is  enough  to  say  that  the  lady  was  thirty-seven  years  of 
age,  was  tapped  by  Dr.  Kidd  at  the  fifth  month  of  pregnancy, 
and  that  I  found  her  in  Dublin  on  March  21,  1876,  suffering 
from  peritonitis  and  obstructed  intestines,  and  almost  moribund. 
Some  relief  was  obtained  by  tapping  and  the  removal  of  nine 
pints  of  ovarian  fluid  from  the  peritoneal  cavity  on  the  evening 
of  the  same  day.  The  next  morning  I  took  away  a  burst 
ovarian  cyst.  The  child  was  born  nine  hours  after.  The 
patient  went  on  well  for  two  days,  but  died  on  the  fifth  day 
after  the  operation.  Considering  that  this  is  the  only  death 
after  my  operations  during  pregnancy,  and  the  desperate  cir- 
cumstances under  which  this  one  was  undertaken,  it  will  cer- 
tainly appear  that  pregnancy  does  not  add  much  to  the  danger 
of  ovariotomy. 

Case  798. — This  lady  was  the  wife  of  a  medical  man.  She 
was  forty-one  years  of  age  and  the  mother  of  six  children.  I 
tapped  a  multilocular  ovarian  cyst  on  September  9,  1876,  and 
took  away  b\  pints  of  ovarian  fluid.  The  relief  was  only  tem- 
porary, and  on  October  12  1  removed  an  ovarian  tumour  weigh- 
ing seven  pounds.  The  uterus  then  extended  upwards  about 
half  way  between  the  pubes  and  umbilicus.  The  pedicle  on 
the  right  side  was  secured  by  a  clamp.  She  recovered  perfectly, 
was  delivered  after  an  easy  labour  on  April  23,  1877,  and  now 
in  1881  is  quite  well. 

Case  817. — The  wife  of  a  soldier  was  sent  to  me  by  Surgeon- 
Major  Perry  and  admitted  into  the  Samaritan  Hospital,  October 
1876.  She  was  twenty-seven  years  of  age,  and  had  one  child 
two  years  old.  There  was  an  ovarian  tumour,  and  she  was  in 
the  third  or  fourth  month  of  pregnancy.  As  there  were  no 
urgent  symptoms  she  left  the  hospital,  but  was  readmitted  on 
December  4.  The  foetal  heart  sounds  were  then  very  distinct 
in  the  right  iliac  region.  The  fundus  uteri  was  seven  inches 
above  the  symphysis  pubis,  and  above  it  was  a  large  ovarian 
cyst.     Ovariotomy  was  performed  on  December  11.     A  short 


454     PRACTICAL  CONCLUSIONS  AS  TO  THE  TREATMENT 

pedicle  on  the  left  side  was  transfixed  and  tied  in  two  parts. 
The  tumour  was  cut  off  near  the  ligature  and  the  ligature 
returned.  The  tumour  weighed  llijr  lbs.,  nine  pints  of  fluid, 
2^  lbs.  solid.  When  she  was  convalescent,  on  January  25,  1877, 
uterine  pains  came  on  and  a  child  was  born  alive.  There  was 
very  little  haemorrhage,  and  she  left  the  hospital  on  February  12. 
Dr.  Boulton  reported  the  child  as  a  female  of  twenty-eight 
weeks'  average  development,  but  it  died  about  twenty-six  hours 
after  birth.  She  has  had  two  boys  since,  one  born  in  1878, 
the  other  in  1880,  and  at  this  date  in  1881  is  quite  well. 

Case  879. — The  wife  of  a  surgeon  consulted  me  in  October 
1877,  four  months  after  her  marriage.  She  was  twenty-eight 
years  of  age,  and,  although  unsuspected  at  the  time  of  marriage, 
there  can  be  very  little  doubt  that  ovarian  disease  had  begun  a 
year  or  two  before.  She  was  married  on  June  27,  1877,  and 
pregnancy  may  be  dated  from  the  first  week  in  August.  I 
operated  on  her  on  November  9,  1877.  An  ovarian  tumour 
weighing  ten  pounds  was  removed,  a  short  pedicle  on  the  left 
side  being  secured  in  a  clamp.  Eecovery  was  uninterrupted, 
and  a  well-formed  healthy  child  was  born  after  a  rapid  labour, 
without  any  chloroform  being  taken,  before  Dr.  Brodie  arrived, 
on  April  15,  1878.  She  has  had  two  more  children  since  that 
time,  and  is  well  in  1881. 

Careful  consideration  of  the  cases  just  related  will  lead,  I 
think,  to  the  following  conclusions  : — 

1.  Pregnancy  and  ovarian  disease  may  go  on  together,  and 
may  end  in  the  birth  of  a  living  child  and  the  safety  of  the 
mother. 

2.  But  in  a  large  proportion  of  cases,  probably  in  nearly  all 
where  an  ovarian  tumour  is  large,  there  is  danger  of  abortion  ; 
or,  if  the  pregnancy  proceed  to  the  full  term  of  lingering  labour 
and  a  still-born  child ;  and  throughout  the  later  months  of 
pregnany  there  is  danger  of  sudden  death  to  the  mother  from 
rupture  of  the  cyst  or  rotation  of  its  pedicle. 

3.  Spontaneous  premature  labour  may  not  save  the  mother 
from  these  perils,  and  the  induction  of  premature  labour  artifi- 
cially almost  implies  sacrifice  of  the  child  with  considerable 
risk  to  the  mother. 

4.  There  is  no  proof  that  tapping  an  ovarian  cyst  is  more 
dangerous  during  pregnancy  than  at  any  other  time ;  and  if 


OF   OVARIAN   DISEASE   DURING   PREGNANCY  455 

there  be  a  large  single  cyst,  tapping  will  afford  immediate  relief 
to  distension  at  a  very  slight  risk  to  the  mother,  and  lead  to 
the  natural  termination  of  pregnancy  in  the  birth  of  a  living 
child,  if  proper  precautions  be  taken  to  prevent  the  escape  of 
ovarian  fluid  into  the  peritoneal  cavity,  and  the  entrance  of  air 
into  this  cavity,  and  into  the  cavity  of  the  cyst.  In  cases  of 
multilocular  cyst  tapping  can  be  of  very  little  use. 

5.  In  cases  of  multilocular  cyst,  or  solid  tumour,  the  rule 
should  be  to  remove  the  tumour  in  an  early  period  of  pregnancy ; 
and  if  an  ovarian  cyst  should  burst  during  pregnancy  at  any 
period,  removal  of  the  cyst  and  complete  cleansing  of  the  peri- 
toneal cavity  may  save  the  life  of  the  mother,  and  pregnancy 
may  go  on  to  the  full  term. 

6.  Of  three  cases  on  record  where  a  pregnant  uterus  has 
been  punctured  during  ovariotomy,  the  only  recovery  was  in  the 
one  case  where  the  uterus  was  emptied  before  the  completion 
of  the  operation,  and  the  opening  in  its  wall  closed  by  suture. 


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Other  children  born, 
May  1873,  August  1870 
and  1878.     Well  in  1881 
Another  child  born,  Jan. 
7,  1877.     Ill  with  pul- 
monary disease  and  an 
abdominal  tumour  of 
doubtful  nature  in  L881 
Another  child  born, 
May  1873. 
Well  in  1881 
Living  children  born, 
Dec.  1873  and  March 
1870.     Another  expected 
July  1877.     No  report 

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INCOMPLETE    OPERATIONS  457 


CHAPTER   XIV. 

ON   INCOMPLETE   OVARIOTOMY  AND.  EXPLORATORY   INCISIONS 

When  I  began  to  publish  every  case  where  I  had  completed 
the  operation  of  ovariotomy,  and  published  in  separate  series 
cases  where  the  operation  was  commenced  but  not  completed, 
and  cases  where  an  exploratory  incision  only  was  made,  I  had 
to  reply  to  objections  advanced  by  critics  who  considered  that 
the  fatal  cases  of  exploratory  and  incomplete  operations  ought 
to  be  counted  among  the  unsuccessful  cases  of  ovariotomy.  If 
I  asked  whether  the  cases  which  recovered  from  the  operation 
when  only  part  of  the  cyst  had  been  removed,  or  when  a  cyst 
had  been  simply  emptied,  should  be  counted  among  the  suc- 
cessful cases,  the  answer  was,  '  Certainly  not,  because  ovari- 
otomy had  been  only  attempted,  and  the  attempt  had  failed.' 
One  great  reason  why  ovariotomy  was  so  long  before  it  was 
received  at  all  cordially  by  the  profession  was,  that  incomplete 
cases,  or  cases  of  simple  incision,  had  been  classed  among  cases 
of  ovariotomy,  while  unsuccessful  cases  were  left  unpublished. 
In  the  so-called  statistical  tables,  cases  of  complete  and  incom- 
plete ovariotomy  and  of  exploratory  incisions  were  so  grouped 
together  that  it  was  impossible  to  ascertain,  without  a  good 
deal  of  inquiry,  what  were  the  real  results  of  even  the  published 
cases ;  and  in  some  of  the  most  recent  tables  this  confusion  is 
still  more  deplorable.  I  thought  the  best  way  of  avoiding  this 
error  would  be  to  give  a  truthful  and  exact  account  of  every 
case  in  the  order  of  its  occurrence,  showing  how  frequently  the 
attempt  to  remove  an  ovarian  tumour  had  been  made,  how 
often  it  had  succeeded,  what  were  the  results  of  completed 
operations,  how  often  the  attempt  had  been  only  partially 
successful  or  had  failed,  what  were  the  results  of  incomplete 
operations,  how  often  diagnosis  had  been  so  doubtful  that  an 
exploratory  incision  was  necessary  before  the  doubt  could  be 


458  INCOMPLETE   OPERATIONS 

solved,  and  what  risk  the  patient  incurred  by  submitting  to  an 
exploratory  incision.  This  plan  appeared,  and  still  appears  to 
be,  better  calculated  than  any  other  to  present  a  true  picture 
of  the  occurrence  of  actual  daily  practice,  and  I  think  the  tables 
which  I  published  in  1872,  including  every  case  where  I 
attempted  to  perform  ovariotomy,  but  had  not  completely  suc- 
ceeded, or  had  made  an  exploratory  incision  either  to  satisfy 
my  own  doubts  or  those  of  others,  or  in  compliance  with  the 
earnest  solicitation  of  a  patient,  gave  a  far  better  opportunity 
of  forming  a  correct  estimate  of  the  real  results  of  ovariotomy 
than  if  the  fifty-two  cases  which  they  together  contained  had 
been  included  among  the  completed  cases  of  ovariotomy.  The 
proportionate  mortality  would  have  been  slightly  increased  ; 
instead  of  500  cases,  with  127  deaths,  and  a  mortality  of  25*4 
per  cent.,  we  should  have  had  552  cases,  with  146  deaths,  and 
a  mortality  of  26*44  per  cent. — a  difference  of  not  much  more 
than  1  per  cent. — while  discredit  would  have  been  thrown  upon 
the  whole  series  of  cases  by  the  manifest  fallacy  that  cases 
were  enumerated  as  ovariotomy  where  the  operation  had  only 
been  begun  and  could  not  be  finished,  and  that  the  patients 
who  recovered  from  the  operation  were  not  cured  of  the  disease 
even  if  they  gained  some  temporary  benefit.  By  correctly 
classifying  all  the  cases,  as  I  did  in  three  series,  it  appears  to 
me  that  all  possible  objection  was  removed.  It  was  seen  that 
while  in  some  fourteen  years  the  operation  of  ovariotomy  had 
been  completed  by  me  five  hundred  times,  it  had  during  the 
same  period  been  found  impossible  to  complete  it  in  twenty- 
eight  cases,  and  that  in  twenty-four  other  cases  exploratory 
incisions  were  necessary  to  perfect  diagnosis. 

On  looking  over  the  tables  formerly  published,  and  in  adding 
cases  of  exploratory  and  incomplete  operations  since,  thirty- 
three  in  number,  making  85,  to  the  1,000  completed  ovariotomy 
cases,  I  find  that  in  almost  every  case  doubts  or  suspicions 
entertained  before  the  incision  was  made  were  confirmed,  and  I 
scarcely  recollect  a  case  where  an  exploratory  incision  was 
thought  to  be  necessary  and  which  proved  to  be  an  ordinary 
case  of  ovarian  disease.  Occasionally,  after  commencing  by  an 
exploratory  incision,  I  have  found  it  possible  to  remove  an 
ovarian  tumour,  but  there  has  always  been  some  peculiarity  in 
the  case  which  led  to  this  unusually  cautious  mode  of  proce- 


COMPAEATIVELY    RARE  459 

dure.  Any  one  who  will  carefully  study  the  chapter  on  diagnosis, 
in  the  earlier  part  of  this  volume,  will  find,  I  think,  good 
reason  for  believing  that  the  diagnosis  of  ovarian  tumours,  and 
of  the  conditions  favourable  or  otherwise  for  operation,  is 
already  as  well  established  as  that  of  any  other  form  of  disease 
requiring  surgical  operation.  No  surgeon  about  to  attempt  to 
relieve  a  strangulated  hernia  can  foresee  exactly  the  conditions' 
he  may  meet  with  ;  the  lithotomist  may  find  a  larger  or  smaller 
stone  than  he  expects  ;  aneurism  is  not  always  cured  by  the 
ligature  of  the  artery  supposed  to  be  involved ;  and  mammary 
tumours  supposed  to  be  malignant  are  found  not  to  be  so  in 
some  cases  after  removal,  or  those  supposed  to  be  innocent 
prove  to  be  malignant.  Indeed,  throughout  all  surgery  we 
share  with  physicians  the  difficulty  of  practising  an  ars  conjec- 
turalis,  and  it  is  no  reproach  to  a  surgeon,  if,  acknowledging 
doubt,  he  endeavours  to  clear  up  that  doubt  by  commencing 
his  operation  with  an  exploratory  incision.  The  fact  that  only 
twenty-four  cases  of  exploratory  incision  occurred  during  the 
period  in  which  I  completed  ovariotomy  five  hundred  times 
proves  that  in  a  large  majority  of  cases  an  accurate  diagnosis 
may  be  made  even  without  an  exploratory  incision.  With  our 
present  knowledge  it  is  almost  incomprehensible  that  Dr. 
Frederick  Bird  should  have  been  compelled  by  Mr.  Caesar 
Hawkins  to  acknowledge  that,  in  addition  to  the  few  cases  of 
ovariotomy  which  he  had  completed  and  published,  he  had 
also  made  exploratory  incisions,  or  had  commenced  the  opera- 
tion and  had  failed  to  complete  it,  in  about  forty  other  cases 
which  he  had  neither  published  nor  alluded  to  until  questioned 
by  Mr.  Hawkins.  And  there  can  be  no  doubt  that  if  a  surgeon 
for  every  case  of  completed  ovariotomy  must  necessarily  en- 
counter such  difficulties  that  he  would  be  compelled  to  leave 
several  cases  incomplete,  or  meet  with  such  insuperable  diffi- 
culties in  diagnosis  that  he  could  only  satisfactorily  clear  them 
up  by  an  incision,  it  would  be  a  very  grave  objection  to  the 
principle  of  the  operation.  Happily,  with  advancing  knowledge 
doubts  are  being  cleared  up  and  difficulties  lessened,  exploratory 
incisions  are  becoming  less  frequently  necessary,  and  incomplete 
are  bearing  a  diminishing  proportion  to  completed  operations. 
Concurrently  with  the  second  series  of  500  ovariotomies,  T  had 
only  thirty-three  cases  of  incomplete  operation  or  exploratory 


460  RESULTS   OF 

incision,  with  a  loss  of  fourteen  patients — thus  reducing  the 
proportion  of  unsuccessful  cases  from  10  per  cent,  to  about  6^- — 
and  this  even  now  goes  on  lessening.  In  fact,  I  had  only  three 
cases  of  incomplete  operation  during  the  two  years  which  in- 
tervened between  my  lectures  at  the  College  of  Surgeons  and 
the  making  up  of  my  1,000  completed  ovariotomies. 

Of  the  first  twenty- four  patients  subjected  to  exploring 
incisions  seventeen  recovered  from  the  incision  or  were  relieved 
by  it ;  in  seven  cases  death  followed  from  three  to  ten  days 
after  incision.  In  two  recovery  appears  to  have  been  perma- 
nent and  complete.  In  others  the  disease  has  gone  on  very 
much  as  if  the  patient  had  been  only  tapped ;  the  patients 
were  as  much  or  more  relieved  than  by  tapping,  but  not 
permanently  cured. 

The  cases  of  incomplete  operation  as  distinguished  from 
those  of  simple  exploratory  incision  might  perhaps  have  been 
included  in  the  same  table  as  in  many  of  them  difficulties  were 
anticipated  and  an  exploratory  incision  even  proposed,  but  in 
almost  all  something  more  than  an  incision  was  done,  such 
as  separation  of  adhesions,  or  emptying,  or  partial  removal  of 
the  cysts. 

Of  the  twenty-eight  patients  so  treated  death  was  hastened 
by  the  operation  in  eleven  or  twelve,  they  having  died  at  various 
periods  from  one  to  eleven  days  afterwards.  Others  were 
neither  more  nor  less  relieved  than  they  would  have  been  by 
an  ordinary  tapping.  In  some  the  natural  progress  and  ter- 
mination of  the  disease  were  neither  hastened  nor  checked, 
in  some  life  was  certainly  prolonged,  and  in  some  recovery 
appeared  for  a  time  to  be  complete. 

In  three  cases  none  of  the  cyst  was  removed,  but  a  perma- 
nent opening  was  kept  up,  and  alter  suppurative  inflammation 
a  cure  obtained,  which  in  the  following  case  was  complete. 

Early  in  December  1864,  I  was  asked  by  Mr.  Nicholson,  of 
Stratford  Green,  to  see  a  housemaid  twenty-two  years  of  age, 
and  single,  who  was  suffering  under  ovarian  disease.  A  tumour 
was  felt  occupying  the  lower  part  of  the  belly,  and  rising  four 
or  five  inches  above  the  umbilicus.  It  was  not  tender  on  pres- 
sure ;  fluctuation  in  it  was  perceptible,  but  was  not  very  dis- 
tinct. The  patient  had  commenced  to  menstruate  at  the  age 
of  fourteen,  and  had  always  lost  a  good  deal  of  blood  every 


INCOMPLETE   OPERATIONS  461 

fortnight.  The  uterus  was  high  and  rather  far  back  ;  the  cer- 
vix was  movable  ;  while  a  soft  elastic  tumour  was  to  be  felt 
depressing  the  anterior  wall  of  the  vagina.  On  the  father's  side 
the  patient  came  of  a  strong  family ;  her  mother  had,  how- 
ever, been  delicate.  She  herself  had  at  one  time  been  sup- 
posed to  have  a  hernia  on  the  right  side.  No  trace  of  it  was 
felt. 

About  eight  months  before  I  saw  her  the  patient  was  much 
troubled  with  pain  in  the  right  hip,  and  shortly  afterwards  she 
discovered  a  small  tumour  in  the  lower  part  of  the  abdomen. 
For  six  months  symptoms  of  pressure  on  the  bladder  super- 
vened occasionally,  and  pain  and  numbness  continued  in  the 
right  leg.  The  tumour  increased  slowly  at  first,  and  then  more 
quickly,  until  it  reached  the  size  already  mentioned.  The 
patient  was  advised  to  wait  before  anything  was  done.  On  New 
Year's  Day,  1865,  she  had  a  smart  attack  of  pain  in  the  right 
thigh,  and  three  days  later  I  felt  some  recent  lymph  over  the 
anterior  surface  of  the  tumour. 

The  patient  was  admitted  to  the  Samaritan  Hospital  on 
January  17,  1865.  The  catamenia  had  just  come  on.  When 
they  ceased — after  some  consultations  rendered  necessary  by  a 
questionable  state  of  the  apex  of  the  right  lung — it  was 
decided  not  to  delay  ovariotomy  by  any  preliminary  tapping, 
and  on  February  6,  1865,  Dr.  Parson  having  chloroformed  the 
patient  at  3  p.m.,  Drs.  Dehn,  of  Hamburg,  Marion  Sims,  and 
Mr.  Wright,  of  Nottingham,  being  present,  I  made  an  incision 
from  one  inch  below  the  umbilicus  downwards  for  five  inches. 
There  were  no  adhesions  anteriorly,  but  after  tapping  the 
principal  cyst,  and  emptying  it  of  several  pints  of  fluid  con- 
taining much  blood,  its  attachments  to  the  brim  of  the  pelvis 
and  to  the  right  side  of  the  uterus  were  found  to  be  so  close 
that  I  resolved  not  to  attempt  their  separation,  but  to  replace 
the  empty  cyst.  There  was,  however,  such  free  haemorrhage 
from  the  opening  into  the  cyst  made  by  the  trocar,  and  even 
from  the  little  punctures  made  by  the  hooks  which  seized  the 
cyst  wall,  that  it  was  obviously  unsafe  to  return  it;  and  I 
transfixed  the  edges  of  the  external  parietal  wound,  and  of  the 
cyst  wound,  with  a  hare-lip  pin,  and  secured  them  together  with 
a  twisted  suture.  The  rest  of  the  abdominal  wound  was  closed 
with  four  deep  silk  sutures  above  the  pin,  and  one  below  i(. 


462  CASES    OF 

The  patient  rallied  well ;  pain  was  not  excessive.  Twenty 
drops  of  laudanum  were  given  at  5.  At  eight  she  was  easier 
than  she  had  been,  but  the  skin  was  hot ;  the  tongue  very  dry  ; 
the  lips  parched;  the  pulse  120;  respiration  52.  A  pint  of 
clear  urine  was  drawn  off.  I  thought  of  bleeding,  but  resolved 
to  wait  for  two  hours  to  see  whether  perspiration  would  break 
out,  the  aspect  being  good  and  the  state  of  the  urine  favour- 
able. At  10.30  the  patient  was  found  to  have  been  sick;  the 
pulse  was  136,  the  respiration  52.  At  10.45  I  bled  to  10  oz. 
rapidly  in  a  full  stream.  At  11  the  pulse  was  124,  the  respira- 
tion 48  ;  the  face  rather  pallid ;  the  pulse  still  incompressible 
although  fuller  than  before  the  bleeding.  At  12.20  the  pulse 
was  124,  the  respiration  40.  Next  day  the  face  was  flushed, 
and  the  tongue  still  parched ;  the  skin,  although  hot,  was 
moist ;  the  pulse,  120  ;  respiration,  28.  I  cut  away  the  thread 
around  the  pin,  but  left  the  pin  itself.  On  the  second  day 
the  patient  was  much  better;  her  pulse  was  only  116.  The 
stitches  were  removed  in  due  time,  and  a  very  free  discharge 
of  serum  gradually  set  up,  just  at  the  point  where  the  cyst  had 
been  pinned  to  the  abdominal  wall.  Convalescence  progressed, 
and  on  February  26  the  patient  was  sent  to  Eastbourne.  I  next 
saw  her  on  May  11.  There  was  then  a  very  little  discharge 
from  the  bottom  of  the  cicatrix,  and  a  slight  hardness  and 
elastic  swelling  felt  per  vaginam.  The  abdominal  tumour  had 
disappeared.  She  returned  to  her  situation,  and  I  saw  her 
again  in  July  in  excellent  health,  the  catamenia  being  regular, 
and  with  a  very  slight  moisture  only  at  the  lower  end  of  the 
cicatrix. 

She  became  servant  in  a  family  at  Camberwell,  where  she 
remained  in  excellent  health,  and  called  on  me  quite  strong 
in  February  1868.  I  saw  her  early  in  1872  in  excellent 
health. 

In  the  second  of  these  three  cases  the  patient  was  in  good 
health  for  nearly  three  years  after  the  operation,  and  then  died 
almost  immediately  after  a  subcutaneous  injection  of  morphia 
in  Germany  ;  and  in  the  third  case  a  careful  examination,  in 
July  1872,  failed  to  detect  any  trace  of  the  cyst. 

The  result  of  the  thirty-three  cases  of  incision  and  incom- 
plete operation  during  the  time  of  my  second  series  of  500 
ovariotomies  was  that  ten  women  died  within  ten  days  of  the 


INCOMPLETE   OPERATION  463 

operation,  four  died  between  the  tenth  and  the  fiftieth  day, 
eleven  lived  from  five  months  to  five  years  afterwards,  five  are 
not  only  alive  but  well  in  1881,  and  three  recovered,  but  have 
made  no  report  since.  The  mortality  upon  the  whole  eighty- 
five  cases  is  38*8  per  cent.,  and  if  we  add  the  eighty-five  cases 
to  the  1,000  completed  operations,  the  number  of  deaths  is 
increased  by  thirty -three,  making  together  265;  and  this  raises 
the  percentage  of  mortality  a  fraction  more  than  1  per  cent., 
so  that  instead  of  being  23'2  it  mounts  to  24*4,  a  result  not 
much  differing  from  what  was  found  in  the  first  series  of  500 
ovariotomies  with  their  attendant  incomplete  operations. 

In  May  1877,  I  attempted  to  remove  an  ovarian  cyst  from 
an  unmarried  girl,  in  the  Samaritan  Hospital,  who  was  about 
seventeen  years  of  age.  I  found  such  inseparable  attachments 
that  I  contented  myself  with  clearing  the  cyst  cavity  of  six 
pints  of  purulent  fluid  and  flakes  of  lymph,  and  closing  the 
cyst  and  abdominal  wall  round  a  glass  tube — covering  the  end 
of  the  tube  with  a  carbolized  sponge.  The  patient  remained 
in  the  hospital  till  August  16,  suffering  from  a  good  deal  of 
fever,  treated  by  the  ice-cap  and  quinine,  while  the  cyst  was 
duly  washed  out  with  carbolized  solutions.  After  she  left  the 
hospital  sulphurous  acid  was  substituted  for  the  carbolic  with 
an  immediate  change  for  the  better  in  the  condition  of  the 
patient.  A  continuous  stream  of  the  diluted  solution  was  kept 
running  through  the  cyst  by  a  syphon  arrangement,  and  at 
the  same  time  she  was  vigorously  nourished.  She  recovered 
sufficiently  well  to  become  a  useful  nurse,  although  there  was 
at  times  some  discharge  from  the  sinus  in  the  abdominal  wall 
which  never  entirely  closed.  She  was  nursing  in  the  Samaritan 
Hospital  in  the  early  part  of  1881,  but  died  towards  the  end  of 
the  year,  or  the  beginning  of  1882. 

In  1880,  and  in  1881  I  twice  laid  open  adherent  cysts,  but 
did  not  attempt  to  remove  them,  trusting  to  the  free  escape 
of  their  fluid  contents  into  the  peritoneal  cavity  and  absorption. 
In  neither  case,  so  far,  has  there  been  any  sign  of  reforma- 
1  ion  of  fluid. 

The  painful  position  of  a  surgeon  who  has  laid  bare  an 
ovarian  tumour,  has  partly  emptied  it,  has  possibly  separated 
Borne  adhesions,  and  then  begins  to  fear  that  he  cannot  com- 
pletely remove  Hx-  tumour,  can  only  be  estimated  by  those 


464  PROCEDURE   WHEN   COMPLETION   IS   IMPOSSIBLE 

who  have  unexpectedly  found  themselves  in  similar  difficulties. 
If  the  difficulty  is  recognized  early,  and  the  cyst  only  exposed 
and  emptied,  the  patient  is  scarcely  in  a  worse  condition  than 
after  tapping.  Indeed,  the  incision  leads  to  the  avoidance  of 
some  of  the  dangers  of  tapping ;  the  surgeon  can  see  what 
vessels  he  wounds,  and  he  can  close  the  opening  in  the  cyst  if 
he  pleases,  while  a  short  incision  in  the  abdominal  wall  can  by 
itself  add  little  to  the  risk  submitted  to  by  the  patient.  But 
if  extensive  adhesions  have  been  separated,  the  surgeon  is 
tempted  at  any  risk  to  complete  the  operation  by  the  feeling 
that  he  can  hardly  leave  his  patient  in  a  worse  state,  and  that 
her  only  hope  is  in  his  boldly  following  out  his  intentions.  In 
the  very  first  case  I  ever  operated  on,  the  patient  recovered 
from  the  incision,  died  four  months  afterwards  from  spontane- 
ous rupture  of  the  cyst  into  the  peritoneal  cavity,  when  it 
was  found  that  there  would  have  been  no  insuperable  diffi- 
culty if  the  operation  had  been  proceeded  with.  On  the  other 
hand,  post-mortem  examination  has  shown  that  some  of  the 
tumours  could  not  have  been  removed  during  the  life  of  the 
patient,  as  they  could  only  be  separated  after  death  by  careful 
dissection. 

In  any  case  where  difficulty  threatens  to  be  insuperable, 
rather  than  persevere  at  any  risk,  the  surgeon  acts  more  pru- 
dently if  he  proceed  after  the  manner  described  at  page  461. 
In  this  case  the  cyst-opening  and  wound  were  closed,  but  after- 
wards opened,  and  no  return  of  the  disease  had  appeared  seven 
years  after  the  operation.  In  the  cases  where  drainage  proved 
so  successful,  complete  recovery  following  suppuration,  a  drain- 
age-tube or  catheter  was  fixed  in  the  empty  cyst  and  brought 
out  through  the  wound,  which  was  closed  around  it  at  the  time 
of  operation. 


BATTEY  S    OPERATION  465 


CHAPTEE   XV. 

RECENT   EXTENSIONS   OF   OVARIOTOMY 

There  are  no  means  of  judging  what  would  be  the  risk  of 
simple  castration  in  ordinary  adult  women.  But  from  what 
we  know  of  it  as  practised  on  the  lower  animals  it  would 
probably  be  trifling.  It  is  not,  however,  a  matter  of  much 
practical  importance,  since  instinctively  and  theoretically  right 
as  may  be  the  Aborigines  of  Australia  in  performing  it  for  the 
prevention  of  hereditary  disease  and  deformity,  it  is  never 
likely  in  civilised  life  to  be  substituted  for  the  imperfect 
restraint  of  moral  force. 

Our  modern  surgery  has  shown  what  can  be  legitimately 
accomplished  in  the  way  of  extirpating  ovarian  cysts,  and  with 
what  results.  Without  this  no  one  would  have  thought  of 
treating  functional  diseases  of  the  ovaries  by  the  same  surgical 
operation.  Battey  proposed  and  did  so  when  he  castrated  a 
young  woman  in  1872,  acting,  as  there  is  reason  to  believe, 
independently  of  any  acquaintance  with  the  suggestion  made  by 
Blundell  in  a  paper  read  before  the  Medical  and  Chirugical 
Society  in  1823,  in  which  he  said  that  'extirpation  of  the 
ovaries  would  probably  be  found  an  effectual  remedy  in  the 
worst  cases  of  dysmenorrhea  and  in  bleeding  from  monthly 
determination  in  the  inverted  womb  where  the  extirpation  of 
that  organ  was  rejected.'  Though  the  procedure  had  about  it 
at  first  sight  an  air  of  plausibility,  it  was  as  a  piece  of  surgery 
about  on  a  par  with  amputating  for  an  aneurism.  He  had  to 
deal  with  organs  supposed  to  be  at  fault  and  to  prevent  the 
mischief  they  were  causing.  Two  alternatives  were  at  his 
choice ;  he  could  either  cut  out  the  ovaries,  or  he  could  try  to 
bring  about  their  atrophy.  He  took  the  first,  and  nothing 
in  what  he  has  said  or  written  shows  that  he  ever  thought  the 
•'  cond  possible. 

H  11 


466  STATISTICS   OF   BATTEY'S   OPERATION 

When  Bell  snipped  out  a  length  of  nerve,  or  when  the 
surgeons  of  to-day  have  stretched  a  nerve  to  stop  a  neuralgic 
pain,  a  well-known  principle  guided  them.  So  it  was  with 
Hunter,  when  he  tied  the  femoral  artery  to  cure  disease  of  the 
popliteal.  And  nature  herself  has  recourse  to  the  same  device 
in  twisting  the  pedicle  of  an  ovarian  tumour.  But  it  is  not 
always  so  easy  as  it  might  seem  to  carry  out  scientific  principles 
in  surgical  practice.  No  one  had  tied  the  spermatic  artery,  and 
no  one  had  cut  or  stretched  the  spermatic  nerve,  and  Battey 
cautiously  withheld  his  hand  from  such  experimental  practice. 
Ovariotomists  had  shown  him  what  was  within  his  power,  and 
he  elected  to  try  that  which  was  possible  and  easy.  So  the 
science  of  the  nineteenth  century  has  had  for  a  time  to  give 
place  to  the  rude  chirurgical  art  of  the  seventeenth.  Other 
surgeons  have  accepted  this  position,  and,  showing  the  human 
tendency  to  revert  to  barbarism,  have  repeatedly  done  the 
operation  of  extirpating  the  ovaries  of  women. 

Battey's  object  was  to  bring  about  premature  old  age  in 
women  who  suffer  from  the  malperformance  of  their  peculiar 
monthly  functions  ;  but  others,  as  Hegar,  have  both  before  and 
since  given  a  wider  range  to  the  idea  of  suspending  the  func- 
tions and  influence  of  the  ovaries.  They  remove  them  to  stop 
the  growth  of  uterine  fibroma  or  myoma,  and  thereby  lessen 
their  hemorrhagic  tendencies.  I  find  in  Emmet's  Gynaecology 
a  summary  by  Dr.  Paul  St.  Munde,  of  what  has  been  done  in 
this  direction:  'Adding  to  51  previously  reported  cases  with 
1 6  deaths,  these  42  of  Hegar  with  7  deaths ;  1 6  by  Freund, 
Schroeder,  Langenbeck,  Martin,  Miiller,  and  Czerny,  with  but 
2  deaths;  10  by  Noeggerath  (unpublished),  2  deaths;  1  by 
Groodell,  fatal ;  and  1  by  Battey,  recovery  (unpublished) ;  we 
have  120  cases  of  Battey's  operation,  with  28  deaths,  or  22#6 
mortality.'  Dr.  Emmet  adds  two  cases,  one  by  Dr.  Thomas 
temporarily  benefited,  the  other  by  Peaslee  dying. 

My  own  experience  is  confined  to  three  cases.  The  good 
effected  may  be  judged  by  the  fact  that  the  first  patient,  who 
was  operated  on  in  January  1878,  has  written  to  me  recently 
expressing  her  gratitude  for  the  relief  she  has  obtained. 

The  second  is  also  grateful.  But  this  and  the  third  ojDera- 
tions  were  so  recently  done  that  it  would  be  premature  to  say 
anything  about  the  result,  although  the  large  uterine  tumour 


CONDITIONS   JUSTIFYING   THE   OPEKATION  467 

which  led  to  the  removal  of  both  ovaries  in  the  third  case 
is  certainly  smaller  than  it  was  before  the  operation. 

Though  I  accept  the  principle,  I  see  that  the  operation  has  a 
very  limited  application,  and  is  so  open  to  abuse  that  its  intro- 
duction in  mental  and  neurotic  cases  is  only  to  be  thought  of 
after  long  trials  of  other  tentative  measures  and  the  deliberate 
sanction  of  experienced  practitioners.  Mortal  diseases  admit 
of  mutilating  and  desperate  remedies.  But  mutilation  for  the 
sake  of  terminable  maladies,  which  are  the  fruits  of  a  vicious 
civilization  or  a  reckless  procreation,  is  rather  a  question  for  the 
moralist  than  the  surgeon.  In  the  case  of  fibroid  growths, 
with  much  bleeding,  the  position  is  not  the  same.  There  life 
is  threatened,  the  danger  constantly  increasing,  and  the  last 
resource  the  very  serious  operation  of  amputation  of  the 
tumour  or  of  the  uterus.  If  it  can  be  proved  that  the  annulment 
of  ovarian  function,  even  at  the  cost  of  the  organs,  arrests  the 
development  of  the  uterine  growth,  or  holds  in  check  its  bleed- 
ing propensities,  then  the  surgeon  might  rightfully  remove  the 
ovaries.  But  that  the  conditions  justifying  such  an  operation 
are  exceedingly  rare  is  evident  from  the  fact  that,  since  his 
first  enunciation  of  the  principle  upon  which  he  proposed  to 
act,  at  the  date  of  the  London  meeting  of  the  International 
Medical  Congress,  Battey  had  only  found  fifteen  cases  in  which  he 
could  see  reason  for  carrying  it  into  practice ;  and  during  the  four 
or  five  years  that  the  subject  has  been  under  my  consideration  I 
have  only  met  with  four  patients  to  whom  I '  could  recom- 
mend the  operation.  One  of  these  still  refuses  the  chance  of 
relief  from  surgery  and  prefers  waiting  to  see  what  may 
happen  from  natural  causes.  My  last  operation  of  the  kind 
was  done  after  consultation  with  Dr.  Priestley  as  the  alter- 
native for  extirpation  of  an  enlarged  uterus  in  a  young  lady  who 
suffered  most  severely  and  whose  health  was  giving  way  to  such 
an  extent  that  any  remedy  seemed  preferable  to  letting  things 
go  on,  or  trusting  to  ordinary  measures.  After  making  an 
exploratory  incision,  extirpation  of  the  ovaries  appeared  to  pre- 
sent the  fewer  difficulties  and  to  offer  the  best  chance  of  safety 
to  the  patient.  And  it  was  done.  What  the  result  may  be 
after  convalescence  remains  to  be  seen.  This  was  a  case  in 
which  I  was  following  out  Hegar's  idea.     The  other  two  opera- 


468  CASES   OF 

tions  were  purely  Battey's.  The  first  of  these  was  very  fully 
reported  in  the  Transactions  of  the  American  Gynaecological 
Society  for  1880,  vol.  iv.  The  patient  was  in  her  fiftieth  year 
and  had  never  been  pregnant,  if  we  except  a  doubtful  abortion 
of  about  two  months,  two  years  after  marriage,  the  result  of 
a  carriage  accident.  Her  history  was  that  of  fourteen  years' 
almost  intolerable  suffering,  with  every  kind  of  experimental 
treatment  suggested  by  the  various  hypothetical  guesses  as  to 
the  cause  of  the  distress.  Apart,  however,  from  all  surmises, 
there  was  the  fact  of  the  absolute  association  of  severe  suffering 
with  pre-menstrual  congestion,  justifying  the  belief  that  ovari- 
otomy performed  with  the  view  of  anticipating  the  climacteric 
would  be  a  legitimate  proceeding.  We  had  deferred  the  ope- 
ration in  the  hope  that  at  the  age  of  forty- nine  the  catamenia 
would  cease  naturally.  But  a  sister  aged  fifty-four  was  still 
menstruating  quite  regularly ;  and  the  patient  felt  that  it  would 
be  quite  impossible  for  her  to  go  through  four  or  five  years 
more  of  such  repeated  suffering.  After  full  consideration 
therefore,  with  Dr.  Frank,  and  with  the  distinguished  retired 
physician  Dr.  C.  J.  B.  Williams,  an  old  friend  of  the  family,  the 
operation  was  done. 

Both  ovaries  were  removed  and  are  now  preserved  in  the 
Royal  College  of  Surgeons.  The  patient  was  very  grateful  for 
the  relief  afforded  her,  although  she  still  has  to  wear  a  truss 
for  a  ventral  hernia.  I  saw  her  in  July  1881  quite  well,  there 
having  been  no  return  of  catamenia  since  April  1880.  Their 
recurrence  after  the  operation  is  explained  by  the  difficulty  I 
had  in  removing  every  fragment  of  the  left  ovary.  I  may 
quote  here  the  conclusion  which  I  drew  from  a  consideration  of 
this  case,  and  submitted  to  my  medical  brethren  in  these 
words :  '  If  I  meet  with  what  I  believe  to  be  a  suitable  case, 
and  a  willing  patient,  I  shall  certainly  do  this  operation 
again ;  removing  both  ovaries  and  being  especially  careful 
that  every  fragment  of  both  ovaries  is  entirely  removed.  I 
should  operate  rather  through  the  abdominal  wall  than  by  the 
vagina  ;  and  be  prepared  for  the  probability  of  intestines  being 
wounded  when  dividing  the  peritoneum.  In  uniting  the  edges 
of  the  wound,  I  should  place  the  sutures  nearer  to  each  other 
than  is  usual  in  ordinary  ovariotomy,  in  order  to  guard  against 
the  occurrence  of  a  ventral  hernia.'     I  still  adhere  to  these  con- 


battey's  operation  469 

elusions.  I  think  it  would  be  only  in  an  exceptional  case, 
where  an  ovary  could  be  felt  low  down  between  the  vagina  and 
the  rectum,  that  a  surgeon  would  now  do  oophorectomy  through 
the  vagina.  In  almost  all  cases  the  abdominal  operation  would 
be  preferred,  and  a  word  of  caution  is  necessary  to  any  one 
about  to  perform  it  under  the  impression  that  it  is  very 
facile  in  execution  ;  for  it  is  more  difficult  than  ordinary  ovari- 
otomy. It  is  not  so  easy  to  divide  the  peritoneum  with- 
out injury  to  the  intestines.  They  have  a  greater  tendency 
to  protrusion  and  cannot  be  replaced  readily  after  they  have 
protruded.  The  opening  into  the  abdomen  should  be  made 
large  enough  to  admit  two  fingers.  With  these  the  uterus  is 
to  be  felt ;  one  finger  being  in  front  of  the  fundus  and  one 
behind  it.  Then,  by  carrying  them  outwards,  first  on  one  side 
and  then  on  the  other,  an  ovary  is  felt  and  may  be  brought  up 
outside  the  abdominal  wall.  Its  connections  with  the  uterus 
are  transfixed  and  tied  in  two  parts  with  a  silk  ligature;  a 
third  ligature  being  placed  behind  the  other  two.  The  ends  of 
all  must  be  snipped  off  close  to  the  knots,  and  the  ovary  cut  away 
not  too  near  the  Ligatures,  which  are  then  allowed  to  slip  down 
into  the  pelvis.  It  is  not  yet  decided  if  the  fimbriae  and  part 
of  the  Fallopian  tube  had  better  be  removed  with  the  ovary. 
If  not  quite  healthy,  they  should  certainly  be  removed.  After 
the  second  ovary  has  been  removed,  the  wound  must  be  closed 
as  usual  after  ovariotomy,  but  with  the  sutures  nearer  to  each 
other,  to  obviate  the  greater  tendency  of  omentum  or  intestines 
to  separate  the  lips  of  the  incision.  The  tension  is  always 
greater  in  these  cases  than  after  removing  large  ovarian  tumours, 
where  the  integuments  have  been  a  long  time  on  the  stretch. 
The  dressing  and  after  treatment  should  be  precisely  the  same 
as  for  a  case  of  ovariotomy. 

Between  January  1878,  the  date  of  this  first  case,  and 
November  1881,  or  nearly  four  years,  I  did  not  repeat  this 
operation,  and  I  had  only  advised  it  in  one  case,  that  lady  not 
being  willing  to  submit  to  it.  The  lady  on  whom  I  operated 
in  November  1881  was  a  widow,  thirty-seven  years  of  age,  a 
patient  of  Mr.  Waters,  of  Jermyn  Street.  She  had  suffered 
excessively  for  about  eighteen  months  from  the  pressure  of  a 
hard  pelvic  tumour,  which  obstructed  the  rectum  and  caused 
great  agony  and  danger  at  each  catamenial  period.     At  the 


470  CAUTION   AGAINST   UNNECESSARY   OPERATIONS 

operation  the  tumour  was  found  to  consist  partly  of  the  right 
ovary,  not  much  enlarged,  and  partly  of  the  thickened  and 
retroflexed  fundus  uteri,  which  I  was  able,  but  with  great  diffi- 
culty, to  draw  up  above  the  brim  of  the  pelvis.  I  removed 
the  right  ovary ;  the  left  was  atrophied,  and  so  closely  applied 
to  the  side  of  the  uterus  that  I  could  not  distinguish  its  out- 
lines, and  did  not  disturb  it.  The  patient  made  a  recovery 
without  any  fever,  and  in  January  1882  was  quite  well,  having 
had  two  menstrual  periods  since  the  operation,  at  three  weeks' 
interval,  without  any  inconvenience.  Here,  of  course,  it  is 
doubtful  how  far  the  relief  is  due  to  removal  of  one  ovary,  or 
to  the  reposition  of  the  displaced  uterus. 

I  have  already  stated  that  in  the  third  case,  although  con- 
valescence is  established  and  the  patient  has  returned  home 
with  the  uterus  diminishing  in  size,  nothing  can  yet  be  said  as 
to  the  result.  But  I  cannot  conclude  this  chapter  without  a 
word  of  caution  against  the  extreme  frequency  with  which  the 
operation  has  been  resorted  to  in  this  country,  and  at  which 
Dr.  Battey  publicly  expressed  his  astonishment,  at  the  meeting 
of  the  Medical  Congress  in  August  last.  Many  cases  where 
the  symptoms  have  been  described  as  sleeplessness,  hysteria, 
nerve  prostration,  dysmenorrhea  or  '  neurasthenic  disorder,' 
have  led  to  Battey 's  operation,  and  in  the  majority  of  such  cases 
healthy  ovaries  have  been  removed.  These  are  just  the  cases  in 
which  Dr.  Weir  Mitchell's  systematic  treatment,  so  successfully 
followed  in  this  country  by  Dr.  Playfair,  should  surely  have 
been  tried.  Dr.  Playfair  says,  '  If  a  case  is  purely  neurasthenic 
it  cannot  under  any  conditions,  I  apprehend,  be  one  even  for 
the  consideration  of  oophorectomy.  If,  on  the  other  hand,  there 
exist  those  chronic  organic  changes  in  the  ovaries  which  afford 
the  most  justifiable  ground  for  this  operation,  any  attempt  at 
their  cure  by  this  treatment  will  inevitably  fail.'  Except  in 
cases  where  bleeding  fibroids  may  call  for  the  removal  of  the 
healthy  ovaries,  we  might  at  least  require  some  evidence  of  the 
ovaries  being  diseased  before  consenting  to  their  extirpation  in 
the  hope  of  curing  any  of  those  vague  nervous  disorders  to 
which  women  are  so  subject,  which  are  often  dispelled  by  moral 
treatment  or  social  changes,  often  benefited  by  measures  which 
can  have  but  little  effect  except  on  the  imagination,  often  return 
after  apparent  cure  in  any  way,  and  leave  the  hapless  beings 


HERNIA    OF    THE    OVARY  471 

the  prey  of  unscrupulous  or  illogically  enthusiastic  experi- 
menters. 

In  a  paper  read  at  the  Medical  and  Chirurgical  Society  in 
January  1882,  on  hernia  of  the  ovary,  Dr.  Barnes  contended 
that  this  condition  furnishes  a  legitimate  motive  for  Battey's 
operation.  He  related  a  case  in  which  an  ovary,  accompanying 
a  hernia  in  the  left  groin,  had  been  removed  from  one  of  his 
patients  in  St.  George's  Hospital.  In  the  discussion  which 
followed  Mr.  Hulke  alluded  to  the  comparative  frequency  of 
this  form  of  hernia,  and  cited  a  case,  under  the  care  of  Mr. 
Lawson  some  years  ago,  in  which  the  suffering  was  so  great 
that  at  the  wish  of  the  patient  the  organ  was  extirpated.  Mr. 
Langton  also  showed,  from  his  own  experience  of  twenty  years 
at  the  Truss  Society,  that  out  of  4,084  cases  of  inguinal  hernia 
no  less  than  67  were  instances  of  these  displaced  ovaries. 
Forty-two  of  the  67  were  congenital,  and  25  acquired.  Those 
which  were  congenital  were  generally  double,  most  of  them 
were  irreducible,  and  the  effects  with  regard  to  the  menstrual 
periods  varied  very  much.  Dr.  Barnes  attributed  the  larger 
number,  being  on  the  left  side,  to  the  greater  length  and  laxity 
of  the  left  round  ligament,  and  the  greater  depth  of  Douglas's 
pouch  on  the  left  than  on  the  right  side ;  and  said  that  in  this 
way  other  pathological  conditions  more  frequently  observed  on 
the  left  than  on  the  right  side,  such  as  hematocele,  might  be 
accounted  for.  He  was  of  opinion  that  where  there  was  pain 
and  distress  it  was  better  to  remove  the  hernial  ovary,  which 
was  liable  to  become  inflamed  and  diseased,  while  trusses  were 
apt  to  cause  distress. 

It  is  somewhat  curious  that  in  all  my  practice  I  have  never 
met  with  a  case  of  hernia  of  the  ovary. 

The  last  reports  which  I  have  respecting  Battey's  operation 
are  those  to  be  found  in  Professor  Agnew's  '  Surgery,'  published 
recently  in  Philadelphia.  He  there  mentions  107  cases,  of 
which  88  were  complete  double  operations.  Sixty-seven  re- 
covered, and  21  died,  a  mortality  of  23*86  per  cent.  In  all  he 
gives  the  figures  of  171  cases  ;  144  by  abdominal  section  with 
a  loss  of  27,  and  27  vaginal,  of  which  5  died. 

While  revising  the  proof  of  this  sheet  I  received  the '  Ingleby 
Lectures  for  1881,'  by  Dr.  Savage,  of  Birmingham.  He  says  that 
while  Battey,  from  all  the  information  he  could  obtain,  found 


472  battey's  operation 

the  mortality  to  be  about  1 8  per  cent.,  in  his  own  (Dr.  Savage's) 
practice  he  has  '  had  40  complete  cases,  with  a  result  that  all 
have  recovered  from  the  operation,  and  I  believe  that  nearly 
every  one  has  been  cured  of  the  disorder  for  which  the  operation 
was  undertaken '  (p.  33).  Dr.  Savage  removes  both  ovary  and 
Fallopian  tube,  but  he  appears  to  agree  with  me  in  the 
impression  that  ligature  of  the  spermatic  artery  has  more  to 
do  with  the  cessation  of  menstruation  after  operation  than  the 
removal  of  the  tube  itself. 


RESULTS    OF    OVAEIOTOMY  473 


CHAPTEE  XVI. 

RESULTS   OF   OVARIOTOMY,   AND   SUBSEQUENT   HISTORY   OF 
PATIENTS   WHO  RECOVERED 

The  fact  that  of  1,000  women  who  have  had  one  or  both  ovaries 
removed  by  me,  768  have  recovered  from  the  operation,  is 
alone  sufficient  to  justify  the  principle  of  the  operation,  and 
to  prove  that  the  mortality — namely,  23*2  per  cent,  on  the 
whole  thousand,  but  which  has  fallen  from  34  in  the  first 
hundred  to  11  in  the  last — is  smaller  than  that  of  many  capital 
operations  which  are  constantly  performed  without  hesitation 
in  suitable  cases.  And  when  we  consider  that  a  patient  from 
whom  one  ovary  has  been  removed  can  scarcely  be  said  to  be 
mutilated,  as  she  is  perfectly  capable  of  fulfilling  all  the  duties 
of  a  wife  and  mother,  menstruating  regularly,  and  bearing 
children  of  both  sexes,  without  any  unusual  suffering  either 
during  pregnancy  or  labour,  all  doubt  as  to  the  '  legitimacy  '  of 
ovariotomy  must  be  at  an  end.  And  the  operation  ought  to 
be  accepted  as  a  more  certain  means  of  saving  life  from 
threatened  death,  restoring  the  sufferer  to  perfect  health,  and 
rendering  her  more  apt  for  all  the  requirements  of  daily  life, 
than  in  the  case  of  a  patient  who  recovers  after  almost  any  other 
surgical  operation. 

Fears  had  been  expressed  that  when  a  patient  recovered 
after  ovariotomy  she  would  in  some  way  or  other  suffer  in  after 
life,  that  she  would  not  menstruate  regularly,  that,  if  she 
married,  she  would  not  have  children,  or  children  of  only  one 
sex,  that  she  would  become  excessively  fat,  or  lose  her  feminine 
appearance  and  her  sexual  instinct,  or  that  her  life  might  be 
shortened  by  some  disease  originating  in  the  operation,  or  its 
consequences  either  upon  some  bodily  organ  or  upon  the  mind. 
In  order  to  ascertain  how  far  any  of  these  fears  were  well 
founded,  or  were   exaggerated,  or  were  purely  imaginary  and 


474  MODE   OF   OBTAINING   INFORMATION 

destitute  of  foundation,  I  asked  every  patient  who  recovered 
to  write  to  me  once  every  year,  on  the  anniversary  of  the 
operation,  giving  me  full  information  as  to  her  state.  Nearly 
all  promised  compliance,  and  a  few  have  written  several  years 
in  succession.  Many  have  written  once  or  twice,  some  I  have 
occasionally  seen ;  but  there  were  so  many  of  whom  I  could 
obtain  no  information  that  in  May  and  June  1872,  and  at  the 
latter  end  of  1881, 1  sent  a  circular  to  every  patient  who  had 
recovered  after  ovariotomy  in  my  practice,  or  to  the  medical 
friend  by  whom  she  was  sent  to  me,  asking  for  information  on 
the  following  points,  and  in  this  form : — 

Name  of  Patient. 
Date  of  operation. 
Present  state  of  health. 
If  married  since — when  ? 
Is  husband  still  alive  ? 
If  any  children — 

Date  of  Births. 

Sex  of  children. 
Anything  unusual  in — 

Pregnancy, 

Or  Labour. 
If  dead,  cause  and  date  of  death. 
Any  other  information  connected  with  the  operation  or  the  Patient  which 

may  seem  important. 

Signature       

Date 


From  circulars  returned  to  me,  and  from  other  sources,  I  am 
able  to  say  that  of  the  1,000  women  who  have  submitted  to 
ovariotomy  by  me  between  February  1858  and  June  1880: — 

449  have  reported  themselves  well  in  1881. 
11  were  well  in  1880  and  have  not  been  heard  of 

since. 
86  were  well  in  1872  and  have  since  made  no  report. 
55  have  reported  themselves  well  within  the  last  ten 

years  without  answering  my  last  letter  in  1881. 
50   have   made   no   report   of  themselves   since  the 
operation. 


651 


HISTORY    OF   WOMEN    WHO   HAVE    RECOVERED  475 

Making  651  either  alive  or  not  known  to  be  dead. 

127  died  after  operation  among  the  first  500. 
105  died  after  operation  among  the  second  500. 
117  have  died  since  recovering  from  the  operation. 


1,000 


Of  the  117  deaths  since  recovery  from  operation : — 
29  have  died  without  cause  assigned. 
43  have  died  of  diseases  of  the  brain,  heart,  or  lungs, 
quite  unconnected  with  the  operation. 
7  have  died  of  diseases  of  the  abdominal  or  pelvic 
organs. 
32  have  died  of  malignant  disease  of  various  parts. 
6  have  died  of  return  of  the  ovarian  disease. 


117 


Of  the  1,000  women  operated  on : — 

439  who  were   married  at  the   time   recovered  from  the 
operation. 

70  of  these  have  since  given  birth  to  126  children. 
36  have  had  one  child  (1  stillborn)  =36 

1 8  have  had  2  children  (one  twins  stillborn)         =  36 
1 1  have  had  3       „         (one  twins)  =  33 

4  have  had  4       „  =16 

1  has  had  5         „  =5 

126 

1  woman  has  had  triplets. 

4  women  have  been  married  a  second  time ;  one  having 
two  children  by  her  second  husband. 
369  have  remained  sterile. 

329  women  unmarried  at  the  time  of  operation  recovered. 
70  of  these  have  since  married. 

1  woman  has  been  married  three  times. 
44    of   these    married   women  have   given   birth   to   99 
children. 


476  HISTORY    OF   WOMEN    WHO   HAVE   RECOVERED 

18  married  women  have  had  1  child  =18  (1  stillborn) 


11 

jj 

55 

2  i 

children 

=  22  (one  twins) 

10 

55 

55 

3 

55 

=  30 

2 

55 

55 

5 

55 

=  10  (3  stillborn) 

2 

55 

55 

6 

55 

=  12 

1 

55 

55 

7 

55 

=    7 

3 

single 

55 

1 

child 

=   3 

102 

Making  a  total  of  228  children  amongst  117  women. 

Many  in  writing  the  report  add  that  they  are  well  and 
strong,  or  better  than  they  have  been  for  many  years,  or  some 
such  phrase,  expressive  of  their  complete  restoration.  A  few 
complain  of  some  trifling  ailment,  and  117  have  died  of  various 
diseases,  some  connected,  others  not  in  any  way  connected,  with 
the  operation. 

Case  713  was  an  old  woman  of  70,  operated  on  in  June 
1875.  Mr.  Whitmarsh,  of  Hackney,  reported  that  at  the  age  of 
72,  a  year  and  a  half  after  operation,  '  she  feels  quite  young 
again — she  has  gained  flesh  wonderfully,  and  the  breasts  are 
developed  like  those  of  a  young  woman.'  She  was  well  in 
December  1876,  but  has  not  been  heard  of  since. 

I  have  not  been  able  to  trace  any  peculiarity  in  the  sub- 
sequent condition  of  patients  who  have  recovered  after  removal 
of  both  ovaries  as  compared  with  those  from  whom  only  one 
was  removed,  except  that  with  only  three  exceptions  there  has 
not  been  menstruation  after  recovery.  One  young  unmarried 
woman  became  very  florid  and  stout ;  but  I  have  seen  nothing 
like  the  excessive  corpulence  anticipated  by  those  whose  expec- 
tations were  based  on  the  results  of  castrating  domesticated 
animals.  Dr.  Jackson,  of  Sheffield,  has  favoured  me  with  the 
particulars  of  a  case  where  he  removed  both  ovaries  in  1868, 
from  a  married  woman  twenty-seven  years  of  age.  She  had  been 
married  nine  years,  had  menstruated  regularly,  but  had  had  no 
children.  She  was  rather  thin,  but  healthy  in  appearance.  The 
abdominal  swelling  had  been  observed  about  two  years.  Both 
ovaries  were  removed,  and  the  patient  recovered  rapidly.  '  At 
about  the   menstrual   period,   on  three  occasions,'   writes   Dr. 


COMPARISON   OF   RESULTS  477 

Jackson,  '  she  had  pains  in  the  back,  headache,  and  bleeding 
from  the  nose.  This  ceased,  and  she  has  since  at  the  periods 
had  headache  and  hot  flushes  in  the  face,  terminating  in  a 
smart  attack  of  diarrhoea,  after  which  she  felt  quite  well.  The 
sexual  appetite  was  absolutely  nil  for  about  two  years,  but  on 
questioning  her  lately  she  said  it  has  slightly  returned.  She 
has  gained  weight  since  the  operation,  probably  to  the  extent 
of  four  stones.  She  is  in  the  enjoyment  of  perfect  health.'  I 
have  ascertained  from  the  husband  or  medical  attendant  of  some 
of  my  own  patients  that  sexual  desire  and  gratification  have 
certainly  not  been  less  than  before  operation.  In  some  cases, 
where  only  one  ovary  was  removed,  desire  had  been  increased. 
One  husband  told  me  that  his  wife  had  been  remarkably  cold 
before  ovariotomy,  but  was  afterwards  extremely  amorous. 
In  several  patients  whose  menstruation  before  operation  had  been 
painful  and  irregular,  it  became  quite  regular  and  normal  after- 
wards. A  few  who  had  been  married  some  years,  but  were 
childless,  have  had  children  since. 

To  the  best  of  my  knowledge  and  belief  this  is  the  first  time 
that  any  such  extended  inquiry  into  the  subsequent  history 
of  patients  who  have  recovered  from  a  capital  operation  has 
been  carried  out.  As  a  rule,  in  all  statistical  returns  from 
hospitals,  the  bare  fact  of  death  or  recovery  is  all  the  informa- 
tion that  is  given,  and  any  attempt  to  follow  up  the  successful 
cases  afterwards  is  found  to  be  excessively  difficult.  Some 
years  ago,  I  endeavoured  to  ascertain  what  became  of  patients 
who  recovered  after  amputation  of  the  thigh.  I  had  good 
reason  for  believing  that  many  died  within  a  year,  but  was 
never  able  to  obtain  anything  like  correct  statistical  informa- 
tion. The  hospital  reporters  of  the  'Lancet'  once  collected 
together  particulars  of  all  the  cases  in  which  amputation 
at  the  hip-joint  had  been  performed  for  several  years  in 
London  hospitals.  A  large  proportion  of  the  patients  died 
within  a  day  or  two  of  the  operation,  and  of  those  who  re- 
covered the  only  one  who  was  alive  a  year  after  operation  was 
a  woman  whose  thigh  I  removed  at  the  hip-joint,  in  the 
Samaritan  hospital,  on  account  of  malignant  disease.  It  is 
well  known  that  patients  who  have  been  cured  of  aneurism, 
either  by  ligature  or  compression,  are  very  apt  to  suffer  from 
the  disease  in  some  other  artery,  but  it  is  left  to  some  future 


478  OVARIOTOMY   AND   OTHER   CAPITAL    OPERATIONS 

inquirer  to  ascertain  the  frequency  and  date  of  such  return  of 
disease.  "We  have  a  little  more  information  as  to  patients  who 
undergo  lithotomy  a  second  time,  but  most  of  the  information 
ends  with  the  immediate  result  of  the  operation,  and  but  little 
is  known  of  the  subsequent  history  of  the  patient.  I  hope 
that  what  has  been  done  in  this  respect  with  regard  to  ovari- 
otomy will  not  only  be  useful  in  enabling  us  to  form  a  correct 
estimate  as  to  the  value  of  this  operation,  but  will  induce  other 
surgeons  to  obtain  similar  information  as  to  the  subsequent 
history  of  patients  who  recover  after  amputation  of  a  limb, 
excision  of  a  large  joint,  lithotomy  or  lithotrity,  ligature  of 
main  arteries,  herniotomy,  or  trephining. 

When  a  surgeon  has  removed  a  large  diseased  ovary  and  the 
woman  recovers,  he  has  in  very  many  cases  the  great  satisfac- 
tion of  feeling  that  his  patient  has  been  restored  to  perfect 
health.  Experience  has  proved  that  the  remaining  ovary  gener- 
ally carries  on  its  functions,  and  that  the  woman  may  become 
the  mother  of  healthy  children  of  both  sexes.  The  patient  is  not 
mutilated  as  by  the  amputation  of  a  limb,  nor  does  the  general 
health  suffer  as  it  frequently  does  after  the  greater  amputations. 
There  certainly  is  nothing  like  the  tendency  to  recurrence 
which  there  is  after  the  removal  of  malignant  tumours, 
probably  by  no  means  so  frequent  occurrence  of  disease  else- 
where as  after  successful  ligature  of  a  diseased  artery,  or  disease 
of  the  opposite  lens  after  successful  removal  of  one  cataract,  or 
formation  of  a  second  calculus  after  a  removal  of  one  by  lith- 
otomy or  lithotrity  ;  and  certainly  no  such  prolonged  suffering 
as  the  chronic  cystitis  which  not  unfrequently  follows  these 
operations. 

The  rule  is  that  by  a  successful  ovariotomy  the  patient  is 
restored  to  a  state  of  health  so  perfect  that  she  and  her  friends 
are  as  surprised  as  they  are  gratified.  But  there  are  exceptions 
to  this  rule.  In  some  cases  a  disease  believed  to  be  innocent 
proves  to  be  malignant,  soon  recurs,  and  proves  fatal  within 
a  few  months,  or  even  within  a  few  weeks  after  apparent 
recovery.  In  other  cases  the  ovary  which  is  left  untouched 
because  it  is  believed  to  be  healthy,  or  so  slightly  diseased 
that  its  removal  is  uncalled  for,  becomes  the  seat  of  disease. 
In  what  proportion  of  cases  this  occurs  we  have  even  now  but 
little  more  information  than  may  be  found  in  this  volume.     It 


RECUKRENCE   OF   OVARIAN   DISEASE  479 

is  only  within  the  last  fifteen  years  that  ovariotomy  has  been 
performed  sufficiently  often  to  furnish  data  for  reliable  statistics, 
and  it  is  difficult  to  ascertain,  even  in  some  of  these  later  cases, 
what  has  been  the  state  of  the  patient's  health  a  few  years 
after  operation.  But  it  would  be  unreasonable  to  expect  that 
in  all  cases  the  ovary  left  in  the  body  would  remain  healthy. 
It  is  for  future  observation  to  decide  how  often  and  in  what 
class  of  cases  a  recurrence  of  disease  may  be  feared.  The  fact 
that  in  my  practice  there  were  11  recurrences  requiring  a 
second  operation  out  of  1,073  patients,  gives  a  proportion  of 
one  in  about  every  97  cases,  and,  so  far  as  I  can  make  out,  the 
character  of  the  cysts  was  generally  'proliferous ;  at  any  rate, 
it  was  so  in  almost  all  the  cases  in  which  an  accurate  report 
has  been  kept  of  the  character  of  the  tumours.  It  is  satis- 
factory, however,  to  learn  that  if  the  remaining  ovary  should 
become  diseased,  the  first  operation  need  not  add  to  the  diffi- 
culty of  a  second,  and  that  when  a  second  ovariotomy  has  been 
performed  it  has  proved  successful  in  eleven  out  of  the  thir- 
teen cases  in  which  I  have  operated,  and  in  the  case  in  which 
Dr.  Atlee  operated  sixteen  years  after  the  first  operation  by 
Dr.  Clay. 

These  rare  exceptions  to  the  general  rule  of  complete  restora- 
tion of  perfect  health  cannot  be  considered  as  invalidating  the 
claim  of  ovariotomy  to  be  considered  as  one  of  the  greatest  of 
surgical  triumphs — relieving  suffering,  saving  life,  restoring 
the  dying  woman  to  perfect  health,  and  enabling  her  to  fulfil 
all  the  duties  of  a  wife  and  mother. 


480  UTERINE   TUMOURS 


CHAPTEK   XVII. 

ON   UTERINE   TUMOURS 

The  Diagnosis  of  Uterine  from  Ovarian  Tumours  is  a  diffi- 
culty which  frequently  arises  in  practice,  which  may  often  be 
solved  with  great  ease,  which  as  often  requires  much  cautious 
investigation,  and  which  in  some  cases  can  only  be  cleared  up 
by  an  exploratory  incision. 

It  is  only  since  ovariotomy  has  become  a  familiar  operation 
that  the  fact  of  uterine  tumours  frequently  attaining  a  very 
large  size  has  become  generally  known.  Even  now  I  am  often 
told  by  men  of  great  experience  that  a  tumour  must  be  ovarian 
because  it  is  too  large  to  be  uterine.  They  have  never  seen 
nor  heard  of  any  such  enlargement  of  the  uterus,  and  are 
astonished  when  I  say  that  the  largest  abdominal  tumours  I 
have  ever  seen  have  been  fibroid  or  fibro-cystic  tumours  of 
the  uterus. 

In  one  of  the  earliest  attempts  to  perform  ovariotomy  in 
Great  Britain,  in  1825,  Mr.  Lizars  fell  into  this  error  of  diag- 
nosis. He  opened  the  abdomen  and  found  a  large  uterine 
tumour.  And  the  first  tumour  supposed  to  be  ovarian  which 
was  removed  in  London — by  Dr.  Granville,  in  1827 — proved 
to  be  a  fibroid  tumour  of  the  uterus,  weighing  eight  pounds. 
Of  the  eight  first  published  cases  by  Kceberle  of  removal  of 
uterine  tumours  by  gastrotomy,  in  only  three  was  the  diagnosis 
of  uterine  tumour  made  accurately  before  operation.  In  two 
the  diagnosis  was  doubtful,  and  in  three  the  tumour  was  be- 
lieved to  be  ovarian.  In  fact  it  has  happened  to  many  surgeons, 
and  to  myself  among  the  number,  that  we  have  commenced 
operations  as  ovariotomy,  and  even  removed  tumours  from  the 
abdomen,  under  the  impression  that  we  were  dealing  with 
diseased  ovaries,  when,  upon  examination,  they  have  proved  to 
be  pedunculate  fibroid  outgrowths  from  the  uterus. 


DIAGNOSIS   OF   UTERINE   TUMOURS  481 

In  my  first  work  on  '  Diseases  of  the  Ovaries,'  published  in 
1865,  I  have  recorded  cases  where  I  removed  large  uterine 
tumours  containing  solid  fibroid  masses  many  pounds  in  weight, 
and  cyst-like  cavities  containing  more  than  twenty  pints  of  fluid, 
these  tumours  being  so  far  pedunculated  outgrowths  from  the 
peritoneal  surface  of  the  uterus  that  the  mobility  of  the  cervix 
uteri  was  free,  and  no  enlargement  of  the  uterine  cavity  could 
be  detected  by  the  sound. 

It  is  quite  certain,  therefore,  that  both  uterine  and  ovarian 
tumours  may  lead  to  very  great  enlargement  of  the  abdomen, 
and  I  can  add  from  my  own  experience  that  the  tumours  may 
be  central  in  position,  or  inclined  to  one  or  other  side  ;  either 
round,  ovoid,  or  irregular  in  form  ;  smooth  or  lobulated  on 
their  surface ;  either  hard,  or  elastic,  or  fluctuating ;  either 
tender  or  insensible  to  pressure ;  and  either  adhering  to  the 
abdominal  wall  or  moving  beneath  it  with  or  without  cre- 
pitation. 

It  is  also  certain  that  there  is  nothing  in  the  history  of  a 
doubtful  case  which  affords  any  very  decisive  assistance  in 
diagnosis  ;  for  although  the  increase  of  ovarian  tumours  is  often 
rapid,  it  is  almost  as  often  slow ;  and  if  the  increase  of  uterine 
tumours  is  generally  slow,  it  is  not  unfrequently  rapid.  Uterine 
haemorrhage,  either  in  the  form  of  excessive  menstruation  or  of 
flooding  at  irregular  intervals,  is  certainly  more  common  in 
uterine  than  in  ovarian  tumours,  but  is  occasionally  associated 
with  the  latter.  Probably  the  rule  is  that  menstruation  is 
scanty  when  a  tumour  is  ovarian,  and  excessive  when  it  is 
uterine,  but  exceptions  to  this  rule  are  numerous ;  and  dis- 
charges of  albuminoid  fluids  from  the  vagina  at  variable  in- 
tervals are  common  in  both  classes  of  tumours. 

So  with  the  age  of  the  patient.  Perhaps  uterine  may  be 
more  common  than  ovarian  tumours  in  old  persons,  and  ovarian 
more  common  than  uterine  tumours  in  young  persons ;  but  it 
is  certain  that  both  uterine  and  ovarian  tumours  are  common 
in  single,  married,  and  widowed  women  at  all  ages  after  puberty, 
and  in  all  conditions  of  life. 

They  are  also  observed  in  some  women  who  are  extremely 
fat,  in  some  who  are  otherwise  healthy  and  well-nourished,  and 
in  some  who  are  extremely  emaciated;  and  there  is  a  facial 
expression  common  to  women  suffering  from  both  classes  of 

i  I 


482  INSPECTION 

tumours,  associated  commonly  with  a  very  florid  complexion 
when  the  tumour  is  uterine.  In  the  majority  of  ovarian  cases 
the  complexion  is  pallid ;  but  in  some  cases,  where  the  patient 
is  fat  or  well-nourished,  the  complexion  may  be  florid. 

Eemembering  the  numerous  exceptions  to  all  the  rules  just 
stated,  we  may  now  inquire  what  may  be  learned  by  the  eye, 
the  touch,  and  the  ear,  in  an  examination  of  the  abdomen ;  in 
other  words,  what  are  the  signs  afforded  by  inspection  and 
measurement,  by  palpation,  and  by  percussion  and  auscultation, 
which  are  of  value  in  diagnosis.  The  results  of  this  inquiry 
may  be  arranged  in  the  following  order : — 

Inspection 

1 .  Visible  enlargement  of  the  abdomen  is  more  often  general 
in  cases  of  ovarian  tumour,  and  partial  in  cases  of  uterine 
tumour,  being  confined  to  the  lower  part  of  the  abdomen  until 
a  very  large  size  has  been  attained. 

2.  The  depression  of  the  umbilicus  is  diminished,  or  the  um- 
bilicus may  become  prominent  in  large  ovarian  cysts.  This  is 
rarely  seen  in  uterine  tumours  unless  fluid  is  also  present  in  the 
peritoneal  cavity. 

3.  Enlargement  of  the  superficial  veins  of  the  abdominal  wall, 
and  oedema  of  the  abdominal  wall  and  of  the  linese  albicantes, 
are  more  general  in  uterine  than  in  ovarian  tumours  of  moderate 
size,  but  are  not  uncommon  when  ovarian  tumoui  s  have  attained 
a  very  large  size. 

4.  When  the  abdominal  wall  is  thin,  both  uterine  and  ovarian 
tumours,  if  not  very  closely  adherent  to  the  abdominal  wall, 
may  be  seen  to  move  downwards  as  a  recumbent  patient  inspires, 
and  upwards  during  expiration,  falling  downwards  and  forwards 
as  she  sits  or  stands,  and  more  or  less  to  either  side  according 
to  the  inclination  of  her  body.  But  nearly  all  uterine  tumours, 
though  visibly  moving  above,  seem  to  be  fixed  below  in  the 
hypogastric  region. 

5.  When  a  recumbent  patient  attempts  to  sit  up  without 
aid  from  any  other  than  the  abdominal  muscles,  the  recti  are 
seen  to  bulge  forward  in  front  of  a  tense  non-adherent  ovarian 
tumour  or  with  a  flaccid  adherent  cyst.  This  is  seldom  well 
marked    in    uterine    tumours,    a    solid    mass  fixed    centrally 


MEASUREMENT,    PALPATION  483 

below  the  umbilicus  interfering  with  the    free    action    of  the 
recti. 


Measurement. 

6.  Increase  in  the  circular  measurement  of  the  abdomen  is 
usually  greater  on  one  side  than  the  other  in  ovarian  tumours. 
In  uterine  tumours  the  increase  is  more  often  symmetrical.  In 
both  classes,  vertical  measurement  shows  the  distance  between 
the  pubes  and  the  sternum  to  be  increased.  But  very  great 
proportionate  increase  of  the  space  from  the  pubes  to  the  um- 
bilicus is  more  common  in  uterine  than  in  ovarian  tumours. 

Palpation. 

7.  Large  masses  of  apparently  solid  matter,  and  smaller 
masses  or  nodules  of  very  hard  or  bone-like  substance,  are  some- 
times observed  in  ovarian  tumours.  But  it  is  excessively  rare 
to  find  such  solid  portions  preponderating  in  an  ovarian  tumour. 
As  a  rule,  the  fluid  or  cystic  portion  is  the  larger,  the  hard  or 
solid  portion  the  smaller,  in  ovarian  tumours.  In  uterine 
tumours,  on  the  contrary,  the  solid  is  the  larger,  the  fluid  the 
smaller,  portion. 

8.  The  mobility  of  ovarian  tumours  is  generally  greater  from 
below  upwards  than  that  of  uterine  tumours,  unless  the  latter 
are  distinctly  pedunculated.  If  one  hand  be  pressed  backwards 
between  the  tumour  and  the  pubes,  an  ovarian  tumour  can 
generally  be  raised  considerably,  and  the  hand  can  sometimes 
be  pressed  backwards  almost  to  the  brim  of  the  pelvis  ;  while  a 
tumour  which  involves  the  body  and  neck  of  the  uterus  cannot 
be  raised  at  all,  or  only  with  difficulty,  and  the  hand  cannot  be 
pressed  down  between  the  pubes  and  the  tumour. 

9.  When  there  is  fluid  free  in  the  peritoneal  cavity,  and  a 
hard  tumour  can  be  felt  on  displacing  this  fluid  by  sudden 
pressure,  the  tumour  may  be  either  uterine  or  ovarian.  If  the 
tumour  be  very  hard  and  the  quantity  of  fluid  small,  the  tumour 
is  probably  uterine  and  the  fluid  ascitic.  An  ovarian  tumour 
which  has  given  way,  and  emptied  one  or  more  of  its  cysts  into 
the  peritoneal  cavity,  is  seldom  hard  or  well-defined  in  outline, 
and  the  quantify  of  fluid  is  often  so  large  that  the  size  and 

i  i  2 


484  PERCUSSION,   AUSCULTATION 

shape  of  the  tumour  cannot  be  ascertained  until  after  removal 
of  the  fluid  by  tapping.  The  characters  of  the  fluid  will  then 
complete  the  diagnosis. 

Percussion. 

10.  As  percussion  elicits  a  dull  sound  all  over  both  uterine 
and  ovarian  tumours,  which  dulness  ceases  abruptly  at  the 
border  or  outline  of  the  tumour  in  all  positions  of  the  patient — 
except  in  the  rare  cases  where  a  cyst  contains  gas,  or  where  a 
coil  of  intestine  is  adherent  in  front  of  a  tumour — percussion 
cannot  afford  much  aid  in  distinguishing  ovarian  from  uterine 
tumours. 

Auscultation. 

11.  In  ovarian  tumours  the  impulse  from  the  aorta  is  often 
perceptible,  and  a  sound  sometimes  accompanies  the  impulse. 
The  sounds  of  the  heart  are  rarely  transmitted,  and  any  distinct 
vascular  murmur  is  excessively  rare.  But  in  about  half  the 
cases  of  uterine  tumours  which  I  have  examined  some  variety  of 
vascular  murmur  may  be  heard.  In  some  cases  the  murmur  is 
tubular,  in  others  vesicular,  and  sometimes  a  tubular  and  a  vesi- 
cular murmur  may  be  heard  in  different  parts  of  a  uterine 
tumour.  These  murmurs  are  synchronous  with  the  pulse.  They 
may  vary  in  intensity  with  the  amount  of  pressure  by  the 
stethoscope,  and  may  disappear  on  very  firm  pressure.  Common 
in  uterine,  very  rare  in  ovarian  tumours,  vascular  murmurs  are 
valuable  aids  in  diagnosis. 

Having  thoroughly  examined  the  abdomen,  the  pelvis  is  next 
to  be  examined  by  the  vagina  and  rectum,  and  a  conjoined 
examination  of  the  tumour  by  the  abdomen  and  pelvis  should 
also  be  made. 

Examination  of  the  vagina  may  at  once  remove  all  doubt,  by 
showing  that  the  os  and  cervix  uteri  are  in  a  healthy  state,  that 
the  uterus  is  normally  mobile,  that  its  cavity  is  neither  elongated 
nor  shortened,  and  that  any  tumour  felt  through  the  vaginal 
wall  is  independent  of  the  uterus.  In  such  a  case  the  tumour 
is  almost  certainly  ovarian.  On  the  contrary,  we  may  find  the 
vagina  more  or  less  completely  obliterated  by  a  solid  mass,  the 


ANEURISMAL   SOUNDS  485 

cervix  uteri  gone,  the  os  reached  with  difficulty,  the  cervical 
canal  so  closed  or  distorted  that  the  sound  cannot  be  passed,  or 
the  uterine  cavity  so  enlarged  that  the  sound  may  pass  many 
inches  beyond  the  normal  length.  Here  the  tumour  is  almost 
certainly  uterine. 

But  it  must  be  remembered  that  considerable  peritoneal  out- 
growths, or  large  growths  within  the  walls  of  the  fundus  or  body 
of  the  uterus,  have  been  observed,  while  the  uterine  cavity  has 
remained  unaltered  in  dimensions  and  the  cervix  in  structure. 
And,  on  the  other  hand,  the  cervix  may  be  drawn  up  out  of 
reach,  or  the  whole  uterus  may  be  elongated,  when  the  con- 
nection with  an  ovarian  tumour  is  close  ;  or  the  lower  portion 
of  an  ovarian  tumour  may  be  so  moulded  to  the  true  pelvis 
that  the  uterus  is  pressed  upwards  and  forwards,  or  flattened 
behind  the  pubes,  so  that  the  tumour  and  the  uterus  are 
either  really  or  apparently  inseparable  from  one  another. 
Abnormal  arterial  impulse  in  the  vagina  and  cervix  uteri 
may  be  felt  in  both  classes  of  tumours.  In  one  case  I  found 
during  the  operation  that  the  pulsations  at  the  base  of  a  uterine 
tumour  arose  from  some  large  vessels  in  a  portion  of  omentum 
which  had  contracted  adhesions  low  down.  The  pulsating 
omental  vessels  had  been  felt  through  the  vagina.  But  I  have 
never  felt  the  vascular  thrill  like  that  of  varicose  aneurism, 
occasionally  felt  in  the  lower  segment  of  a  fibroid  uterus,  in 
any  ovarian  tumour. 

In  reading  this  sentence  it  must  be  borne  in  mind  that  it 
forms  part  of  a  paragraph  on  the  differential  diagnosis  of 
uterine  and  ovarian  tumours,  and  must  therefore  be  taken  as 
indicating  the  simulation  of  aneurismal  disease  by  some 
conditions  of  fibroid  uterus  as  a  point  of  difference  between 
them  and  ovarian  cysts,  as  well  as  the  mere  fact  itself.  In  1876 
Dr.  Bailey,  of  Louisville,  Kentucky,  furnished  me  with  not  only 
a  marked  instance  of  this  condition,  but  a  curious  exemplifica- 
tion of  the  ease  with  which  even  intelligent  and  dispassionate 
commentators  may  put  different  interpretations  upon  the 
simplest  bit  of  text  when  they  overlook  the  context.  In  con- 
sultation with  other  eminent  practitioners,  he  had  seen  a 
patient  who  for  eight  or  ten  years  had  had  fibroid  tumours  of 
the  uterus,  and  he  wrote  to  me  thus :  '  Latterly  a  new  feature 
occurred   in   the  case.     All   the   phenomena  of  an   aneurism 


486  CASE   IN   ILLUSTRATION 

appeared  in  the  lower  segment  of  the  uterus.  A  purring  thrill 
could  be  heard  and  felt  very  distinctly  indeed.  Several  very 
prominent  gynaecologists  unhesitatingly  pronounced  it  aneu- 
rism. Upon  the  paragraph  quoted  from  your  work  I  stated 
that  you  taught  that  the  phenomena  of  varicose  aneurism 
occurred  in  the  lower  segments  of  fibroid  uteri  without  there 
being  aneurism.  Did  I  interpret  your  language  correctly  ? 
Dr.  Atlee,  of  Philadelphia,  as  well  as  the  other  eminent  gentle- 
men, maintained  that  you  merely  expressed  the  idea  that 
fibroid  uteri  had  a  pulsatory  thrill  in  their  lower  segments  that 
was  not  found  when  the  tumours  were  ovarian.  Now  while  this 
is  true,  I  claimed  that  your  language  taught  more  than  this, 
namely,  that  the  lower  segments  of  fibroid  uteri  occasionally 
gave  out  all  the  phenomena  of  varicose  aneurism  when  there 
was  no  aneurism,  and  that  this  was  not  the  case  with  ovarian 
tumours. 

6  Dr.  Atlee  performed  gastrotomy  on  the  28th  inst.,  and  as  the 
shock  and  loss  of  blood  lost  to  him  the  patient  upon  the  table, 
the  dissection  of  the  tissues  where  the  aneurismal  phenomena 
had  presented  themselves  demonstrated  no  aneurism.  So  if  I 
have  interpreted  your  teachings  aright  they  have  in  this  case 
received  additional  support.' 

In  order  to  prevent  any  further  misreading  of  my  words,  in 
which,  however,  I  can  see  nothing  equivocal  when  taken  in  their 
connection,  I  may  notify  that  as  I  cannot  reword  the  matter 
more  clearly  than  he  has  done,  I  fully  accept  Dr.  Bailey's 
construction,  and  gladly  add  his  case  as  an  illustration  of  my 
text. 

The  vaginal  walls  may  be  so  depressed,  when  there  is  much 
fluid  free  in  the  peritoneal  cavity  surrounding  either  a  uterine 
or  an  ovarian  tumour,  as  to  form  a  vaginal  rectocele,  more 
rarely  a  vaginal  cystocele.  And  the  uterus  may  either  remain 
above  the  brim  of  the  pelvis  if  greatly  enlarged,  or  if  fixed  by 
adhesion ;  or  it  may  prolapse  with  the  vagina,  the  os  appear- 
ing at  the  most  depending  part  of  the  protrusion.  Here  the 
uterine  sound  will  generally  remove  all  doubt;  for  if  the 
dimensions  of  the  uterine  cavity  are  normal,  and  the  weight  of 
the  uterus  is  not  increased,  the  tumour  can  hardly  be  uterine. 
And  a  uterus  which  is  not  much  enlarged  can  generally  be 
pushed  up  to  its  normal  position. 


EXAMINATION   BY  VAGINA   AND   RECTUM  487 

In  some  cases  where  the  uterus  is  much  elevated,  it  may  be 
felt  through  the  abdominal  wall  above  the  pubes,  while  the  os 
uteri  cannot  be  reached  by  the  vagina.  The  urethra  may  be 
elongated  or  drawn  to  one  side,  and  the  bladder  may  also  be 
displaced.  If  the  abdominal  tumour  and  the  pelvic  portion  of 
the  tumour  fluctuate,  while  the  uterus  does  not  much  exceed 
its  normal  dimensions,  it  is  almost  certain  that  the  uterus  is 
adherent  to,  and  is  elevated  by,  an  ovarian  tumour. 

Examination  by  the  rectum  may  show  that  the  uterus 
preserves  its  normal  size,  shape,  and  position.  Or  it  may  be 
displaced  by  some  tumour  above  or  in  front  of  it,  and  one  or 
both  ovaries  may  sometimes  be  felt.  This,  however,  is  not 
very  common  if  they  are  not  enlarged  nor  lower  in  the  pelvis 
than  usual.  By  one  finger  in  the  rectum  and  another  in  the 
vagina,  the  consistence,  form,  and  size  of  any  intervening 
structure  can  be  ascertained  and  valuable  information  so  ob- 
tained. And  if  the  sound  be  passed  into  the  uterine  cavity, 
and  examination  then  made  by  the  rectum,  it  is  often  easy  to 
ascertain  whether  any  solid  or  fluid  tumour  is  situated  between 
a  normal  uterus  and  the  rectum,  or  whether  the  uterus  is  fixed 
and  its  posterior  part  enlarged. 

When  a  tumour  can  be  felt  in  the  pelvis  by  vagina  and 
rectum,  as  well  as  in  the  abdomen  by  the  abdominal  wall, 
simultaneous  examination  will  be  required  to  ascertain  if  there 
is  more  than  one  tumour,  and  if  the  uterus  is  independent  or 
not.  Pressing  one  finger  firmly  on  the  cervix  uteri,  and 
moving  the  abdominal  tumour  with  the  other  hand  from  side 
to  side,  then  upwards  and  downwards,  the  uterus  may  be  felt 
to  remain  almost  unaffected  by  the  movements  of  the  tumour, 
or  only  to  receive  some  transmitted  movement  as  the  pelvic 
portion  of  the  tumour  moves.  Here  the  strong  probability  is 
that  the  tumour  is  ovarian.  On  the  other  hand,  every  move- 
ment of  the  abdominal  tumour  may  be  communicated  imme- 
diately to  the  uterus,  which  is  felt  to  move  in  all  directions 
with  the  pelvic  portion  of  the  tumour.  If  this  portion  is  solid, 
it  is  almost  certain  that  the  tumour  is  uterine. 

Cases  are  sometimes  met  with  where  ovarian  tumours  and 
fibroid  tumours  of  the  uterus  are  both  present  at  the  same 
time.  Small  uterine  fibroids  are  often  observed  when  the  only 
important  tumour  is  ovarian.     I  have  seen  a  large  cyst  of  one 


488  UTERINE   FIBROID   OBSTRUCTING   LABOUR 

ovary  and  a  large  uterine  fibroid  coexisting.  I  have  twice 
seen  tumours  of  both  ovaries  present  when  the  uterus  was 
enlarged  by  fibroids,  and  several  cases  where  both  uterus  and 
ovaries  were  simultaneously  affected  by  malignant  disease.  In 
Case  979,  a  patient  of  Sir  Eisdon  Bennett's,  I  removed  an 
ovarian  tumour  weighing  seven  pounds,  and  a  fibroid  outgrowth 
from  the  uterus  weighing  two  pounds.  And  this  year  I  re- 
moved a  dermoid  tumour  of  the  left  ovary,  and  a  fibroid  out- 
growth from  the  right  side  of  the  uterus.  Both  these  patients 
were  young  unmarried  ladies,  and  both  recovered. 

If  these  possible  complications  be  borne  in  mind,  such  an 
examination  as  I  have  suggested  will  in  most  cases  suffice  to 
establish  an  accurate  diagnosis  between  uterine  and  ovarian 
tumours.  In  some  cases  doubt  may  still  remain,  and  explora- 
tory puncture  or  incision  will  then  be  necessary. 

The  history  of  one  patient  whom  I  saw  in  1862,  in  consulta- 
tion with  Dr.  Madge,  when  the  practical  difficulties  were  supposed 
to  be  due  to  the  presence  of  an  ovarian  cyst,  shows  how  almost 
impossible  it  is  under  certain  circumstances,  even  with  the  most 
experienced  assistance,  to  form  an  absolutely  right  opinion  about 
these  suspiciously  situated  fibroid  tumours.  The  particulars 
were  laid  before  the  Obstetrical  Society  by  Dr.  Madge,  and  I 
quote  portions  of  his  report. 

'  Mrs.  H.,  set.  27,  primipara,  well-grown,  in  robust  health, 
and  who  had  gone  her  full  time,  was  taken  with  slight  labour 
pains  on  the  morning  of  May  21.  On  making  an  examination 
in  the  after  part  of  the  day,  I  found  the  pelvis  occupied  by  a 
large  round  tumour,  which  at  first  appeared  to  me  to  be  the 
child's  head.  It  seemed,  however,  to  be  lifting  up,  as  it  were, 
and  pushing  forwards  the  posterior  wall  of  the  vagina.  It  was 
low  down,  and  came  lower,  but  receding  again,  with  every  pain. 
It  appeared  to  fill  up  every  niche  in  the  pelvis,  so  that  the 
finger  could  not  be  passed  around  it.  The  os  uteri  could  not 
be  felt.  Next  day  the  tumour  was  occupying  precisely  the 
same  position.  The  pains  were  still  slight  and  not  frequent, 
and,  as  the  patient  was  in  her  usual  health  and  spirits,  it  was 
considered  advisable  to  wait.  In  the  evening,  with  consider- 
able difficulty,  by  hooking  my  finger  high  up  behind  the  sym- 
physis pubis,  I  was  enabled  to  reach  the  os  uteri ;  it  was  directed 
forwards,  dilated  to  about  the  size  of  a  crown  piece,  and,  as  well 


FIBROID   OUTGROWTH   FROM   UTERUS  489 

as  I  could  make  out,  some  part  of  the  breech  presented.  On 
the  following  day  Dr.  West,  Mr.  Spencer  Wells,  and  Mr.  New- 
ton met  me  in  consultation.  Pains  getting  more  frequent. 
As  some  parts  of  the  tumour  felt  soft  and  yielding,  a  trocar 
was  introduced,  and  a  small  portion  of  fluid  drawn  off.  Vain 
attempts  had  been  made  previously  to  push  the  tumour  above 
the  brim  of  the  pelvis.  Chloroform  having  been  administered, 
and  the  catheter  used,  the  opening  in  the  tumour  was  enlarged. 
Mr.  Spencer  Wells  was  then  enabled  to  push  the  tumour  up- 
wards, and,  with  the  aid  of  a  blunt  hook,  the  child  was  brought 
down  by  the  buttock.  When  born  it  had  some  faint  signs  of 
life,  but  could  not  be  made  to  breathe.  In  the  early  part  of 
the  following  day  the  patient  seemed  to  be  doing  well ;  as  the 
day  advanced,  by  fits  and  starts  she  became  very  excited,  and 
could  not  be  persuaded  to  lie  still.  Peritonitis  set  in  in  the 
afternoon,  and  she  died  on  the  third  day  after  confinement. 

'  Autopsy,  eighteen  hours  after  death. — There  was  a  little 
effused  lymph ;  and  underneath  the  viscera  about  a  pint  of 
bloody  serum.  The  tumour  was  lying  above  and  in  a  line  with 
the  uterus,  nearly  reaching  by  its  upper  border  the  epigastrium. 
It  was  attached  to  the  posterior  aspect  of  the  fundus  uteri  by  a 
long  pedicle,  and  had  thus  been  allowed  to  drop  into  the  pelvis 
at  or  before  the  commencement  of  labour.  The  weight  of 
the  tumour  was  between  one  and  two  pounds,  its  diameter  six 
inches  and  a  half,  and  it  consisted  throughout  of  white  fibrous 
tissue.  Six  small  tumours,  of  the  same  character,  were  studded 
about  the  external  surface  of  the  uterus.' 

On  April  7,  1869,  I  exhibited  at  a  meeting  of  the  Obste- 
trical Society  a  fibroid  outgrowth  from  the  fundus  uteri,  weigh- 
ing thirty-four  pounds  and  ten  ounces,  which  I  had  removed  a 
few  hours  before  from  a  single  woman  thirty-six  years  old. 
Eleven  years  before,  half  her  lower  jaw  had  been  removed  with 
a  fibrous  tumour  by  Mr.  Pemberton  of  Birmingham.  An  ab- 
dominal tumour  was  discovered  in  1864;  it  enlarged  gradually, 
and  she  was  twice  in  the  Birmingham  Hospital.  During  the 
last  six  months  the  tumour  had  increased  rapidly,  and  she 
became  very  weak  and  lost  flesh.  On  admission  to  the  Sama- 
ritan Hospital  a  very  large  abdominal  tumour  could  be  felt, 
but  it  evidently  contained  no  cyst  large  enough  to  warrant 
tapping,  and  did  not  feel  so  hard  as  a  fibroid  tumour  of  the 


490        REMOVAL   OF   FIBROID   OUTGROWTH   BY    GASTROTOMY 

uterus.  No  vascular  murmur  was  audible  in  it,  and  it  appeared 
to  move  quite  independently  of  a  uterus  of  normal  size.  When 
the  tumour  was  exposed  I  was  surprised  to  find  that  it  was  not 
ovarian.  It  sprang  from  the  posterior  surface  of  the  fundus 
uteri  by  a  short  pedicle,  as  shown  in  this  drawing  to  scale 
by  Dr.  Junker,  which  represents  the  posterior  surface  of  the 
uterus,  with  the  Fallopian  tubes,  and  both  ovaries.    A  ruptured 


Graafian  vesicle  is  seen  on  the  left  ovary.  The  pedicle  was 
secured  by  a  clamp  forceps  and  the  tumour  was  cut  away. 
Some  bleeding  spots  where  adhesions  had  been  separated  were 
secured  by  an  acupressure  needle,  and  the  clamp  was  removed. 
Bleeding  vessels  were  secured  by  hare-lip  pins  and  twisted 
sutures,  which  also  served  to  fix  the  bleeding  surface  to  the 
abdominal  wall  by  transfixion.  The  patient  died  on  the  third 
day  after  the  operation,  not  from  any  bleeding,  peritonitis,  or 
other  direct  consequence  of  the  operation,  but  from  fibrinous 
deposit  in  the  right  side  of  the  heart.  Superfibrination  of  the 
blood  had  been  feared  from  the  first  on  account  of  the  rise  in 
the  temperature  of  the  body  from  98-4°  to  101°  within  twelve 
hours,  and  then  rapidly  upwards  to  105'8°.  This  was  accom- 
panied by  hurried  breathing,  and  a  feeble  quick  pulse,  with 
scanty  secretion  of  urine,  charged  with  urates  and  pigments. 
The  first  sound  of  the  heart  became  feeble  more  than  twenty- 
four  hours  before  death,  and  was  inaudible  for  fully  twelve 
hours.  I  observed  at  that  time  that  in  all  operations  where 
peritonitis  may  be  expected,   the   direct   effects   are   far  less 


FIBROCYSTIC   TUMOUR  491 

ssrious  than  its  tendency  to  cause  excess  of  fibrine  in  the  blood 
and  separation  of  the  fibrine  in  the  heart ;  but  at  the  present 
day  we  should  refer  the  cause  of  death  in  this  patient  to 
septicsemia,  and  believe  that  it  might  have  been  averted  by 
antiseptics. 

Dr.  Braxton  Hicks  reported  of  the  tumour  that  '  it  weighed 
thirty-four  pounds  ten  ounces,  was  about  1 7  inches  in  diameter, 
of  a  nearly  globular  form,  having  five  principal  lobules  on  its 
upper  aspect.  These  lobules  were  about  three  inches  in 
diameter,  and  were  partially  pedunculated. 

*  The  tension  of  the  tumour  varied  throughout.  It  had  a 
fluctuation  very  similar  to  that  of  an  ovarian  polycystic  growth, 
which  it  also  resembled  much  in  appearance. 

'  The  interior  was  found  to  be  free  from  cysts,  excepting  a  few 
of  small  size,  of  a  false  kind,  formed  by  separation  of  the 
layers  of  the  tissues,  the  largest  not  an  inch  in  diameter,  of 
irregular  form.  The  tissue  of  which  it  was  composed  was 
arranged  in  a  manner  concentric  with  the  true  centre,  except  in 
the  lobules,  where  it  was  arranged  around  their  centre — differ- 
ing from  the  irregularly  concentric  arrangement  generally  found 
in  mural  uterine  fibroid  growths.  When  cut  into,  serum  exuded 
rather  freely.  The  inside  of  the  growth  was  of  a  pink,  semi- 
translucent  colour. 

'  The  microscopical  examination  of  the  growth  showed  it  to 
be  composed  of  areolar  wavy  tissue,  interlacing  in  all  directions, 
but  the  arrangement  of  the  fibres  was  very  open,  and  between 
them  the  serum  was  held ;  very  little,  if  any,  true  uterine  fibres 
existedo' 

I  have  quoted  the  above  account  of  this  case  as  published 
at  the  time.  My  present  belief,  founded  on  later  experience, 
is  that  if  the  pedicle  or  connection  with  the  fundus  uteri  had 
been  treated  either  m£ra-peritoneally  by  ligature,  or  extra- 
peritoneally  by  a  clamp,  the  result  would  have  been  better  than 
by  the  combined  method  adopted  of  securing  the  stump  to  the 
abdominal  wall. 

The  following  case  of  fibro-cystic  tumour  of  the  uterus,  with 
some  remarks  reprinted  from  the  '  Dublin  Quarterly  Journal  of 
Medical  Science,'  August  1864,  independently  of  their  practical 
importance,  are  historically  interesting  as  a  sort  of  landmark 
indicating  one   stage  in   the  settling  of  the  principles  of  our 


492  FIBROCYSTIC   TUMOUR 

diagnosis  in  these  diseases,  and  the  date  at  which  it  became 
generally  known  that  fibro-cystic  tumours  of  the  uterus  could 
contain  so  large  a  quantity  of  fluid  as  to  bring  them  into  diag- 
nostic competition  with  ovarian  cysts.  It  also  served  as  a 
danger  signal,  marking  the  limits  of  safety  in  any  operative 
proceedings  undertaken  either  for  determining  the  nature  of 
the  growth  or  the  possibility  of  its  removal. 

On  June  20,  1864,  I  arrived  in  Dublin,  having  been  re- 
quested by  Dr.  Stokes  to  come  prepared  to  operate  in  a  case 
which  he  and  Dr.  Beatty  considered  did  not  admit  of  delay.  I 
saw  the  patient  at  once  with  Dr.  Stokes.  She  was  a  single  lady, 
forty-five  years  of  age,  extremely  emaciated,  but  in  excellent 
spirits.  Dr.  Stokes  had  detected  two  apparently  solid  tumours 
in  the  abdomen  ten  years  before.  One  appeared  to  be  central, 
and  a  little  above  the  umbilicus.  The  other  to  the  right  side, 
under  the  anterior  superior  spinous  process  of  the  ilium.  They 
were  then  each  about  the  size  of  a  goose  egg.  Increase  had 
been  slow  at  first,  and  no  alteration  in  dress  had  been  called  for 
until  a  year  ago.  During  the  past  two  months  increase  had 
been  very  rapid.  The  abdomen  was  enormously  distended, 
measuring  fifty-six  inches  in  girth  at  the  level  of  the  umbilicus, 
nineteen  inches  from  the  ensiform  cartilage  to  the  umbilicus, 
sixteen  from  umbilicus  to  symphysis  pubis,  twenty-three  from 
the  right  anterior  superior  spine  of  the  ilium  to  the  umbilicus, 
and  nineteen  inches  from  the  same  process  on  the  left  side  to 
the  umbilicus.  The  greater  prominence  on  the  right  side  was 
very  visible ;  the  skin  covering  the  umbilicus  was  distended  by 
fluid  simulating  an  umbilical  hernia.  Above  the  umbilicus 
fluctuation  was  very  evident ;  but  the  fluid  was  evidently  free 
in  the  peritoneal  cavity,  and  covered  a  solid  or  semi-solid 
tumour  that  could  be  felt  on  displacing  the  fluid  by  deep  pres- 
sure. Some  of  the  superficial  abdominal  veins  were  dilated,  but 
were  not  varicose;  the  fluctuation  below  the  umbilicus  was 
very  indistinct,  and  the  tumour  appeared  to  be  adherent. 
Examination  per  vaginam  showed  the  uterus  was  high,  but 
central ;  the  os  virginal ;  the  cervix  absorbed  or  atrophied,  and 
behind  it  a  small  portion  of  the  tumour  could  be  felt  through 
the  vaginal  wall.  The  uterine  sound  passed  to  three  and  a  half 
inches.  Menstruation  had  passed  off  quite  naturally  early  in 
June ;  but  there  had  been  no  appearance  for  the  previous  six 


OPEEATION  FOR  ITS  REMOVAL  493 

months.  Up  to  that  time  she  had  been  quite  regular.  There 
was  no  history  either  of  excess  or  deficiency.  The  left  leg  was 
slightly  oedematous,  and  she  had  occasionally  felt  it  weak  and 
painful.     She  had  never  been  tapped. 

The  diagnosis  which  I  made  and  wrote  down  was :  '  A 
quantity  of  fluid  free  in  the  peritoneal  cavity  above  the  um- 
bilicus— ascitic  or  ovarian  ?  Below  the  umbilicus  a  large 
attached  multilocular  cyst.'  In  consultation  with  Drs.  Beatty, 
Grordon,  and  Stokes,  it  was  agreed  that  I  should  tap  above  the 
umbilicus,  and  if  the  tumour  appeared  to  be  firmly  adherent 
do  no  more  ;  but  if  the  tumour  was  not  attached,  to  remove 
it.  Accordingly,  Mr.  Macnamara  having  administered  chloro- 
form, and  with  the  kind  and  able  assistance  of  Drs.  Beatty  and 
Grordon,  I  tapped,  with  a  very  long  trocar,  above  the  um- 
bilicus, and  removed  about  thirty  pints  of  clear  rather  viscid 
fluid.  When  all  the  fluid  had  escaped,  the  canula  (which  is 
fourteen  inches  long)  was  passed  in  all  directions  between 
the  surface  of  the  tumour  and  the  abdominal  wall,  proving 
that  there  were  no  adhesions  within  reach.  Fluctuation  was 
also  detected  in  different  parts  of  the  tumour.  After  removing 
the  canula,  and  closing  the  small  opening,  I  made  an  incision 
below  the  umbilicus  about  six  inches  long,  and  exposed  what 
appeared  to  be  two  ovarian  cysts  separated  by  a  deep  fissure.  I 
tapped  that  on  the  left  side,  and  about  ten  pints  of  bloody 
serum  escaped;  two  or  three  pints  more  of  similar  red  fluid 
escaped  after  puncturing  again  within  the  cyst  first  opened, 
by  pushing  on  the  trocar  without  removing  the  canula.  The 
tumour  was  then  withdrawn,  and  found  to  have  two  attach- 
ments— one  above  to  the  tumour  on  the  right  side,  and  one 
below  to  the  uterus.  The  former  attachment  was  broken 
through,  and  two  bleeding  vessels  on  the  torn  surface  of  the 
right  tumour  were  secured  by  silk  ligatures.  The  left  broad 
ligament  was  then  transfixed,  tied  in  two  halves  with  strong 
silk,  and  the  tumour  was  cut  away.  It  then  became  a  question 
what  should  be  done  with  the  tumour  on  the  right  side ;  and, 
looking  to  its  great  size,  solidity,  evident  close  connection  with 
the  transverse  colon,  and  with  the  omentum  which  contained 
some  enormously  distended  veins,  it  was  decided,  with  the  full 
concurrence  of  Drs.  Beatty  and  Grordon  and  Mr.  Macnamara, 
that  no   attempt    to    remove   this  tumour   should   be   made, 


494  ACCOUNT    OF   TUMOURS 

especially  as  the  patient  was  becoming  very  feeble.  The 
wound  was  accordingly  closed,  and  the  patient  placed  in  bed. 
She  was  extremely  feeble,  and  brandy  was  administered  freely ; 
but  she  never  rallied  nor  recovered  consciousness,  continued  to 
sink,  and  died  about  three  hours  after  she  had  begun  to  take 
chloroform. 

The  tumour  which  I  removed  was  examined  by  the  late  Dr. 
Eitchie,  and  I  published  his  very  accurate  report  of  it  fully. 
It  is  now  only  necessary  to  say  that  it  weighed  about  twenty 
pounds,  and  was  almost  entirely  solid.  Its  greatest  length  wTas 
18  inches;  breadth,  12  inches;  thickness,  7*8  inches. 

On  making  a  longitudinal  section  the  tumour  was  found  to 
consist  of  fibrous  tissue,  arranged  in  different  fashions  and  in 
different  states  of  perfection,  and  split  up  by  little  cavities  of 
various  sizes,  containing  serum  more  or  less  transparent.  The 
solid  tissue  was  everywhere  permeated  by  large  blood-vessels, 
and  in  several  places  blood  cysts,  the  size  of  a  barley-corn  to 
that  of  a  pea,  were  demonstrated.  The  largest  cyst  was  at  the 
superior  extremity ;  it  was  about  the  size  of  an  adult  head, 
and  its  internal  surface  presented  traces  of  having  primarily 
been  divided  into  several  compartments. 

The  body  was  examined  after  death  by  Dr.  Gordon,  and  the 
following  is  a  description  of  the  tumour  which  we  did  not 
attempt  to  remove  :  It  consisted  partly  of  a  cyst  and  partly 
of  a  fibro-cystic  tumour.  The  cyst  was  spherical,  about  a  foot 
in  diameter,  empty  (its  contents  having  escaped  through  a 
smooth-margined  opening,  an  inch  in  length),  and  it  adhered 
to  the  anterior  abdominal  wall.  The  inferior  border  of  the 
cyst  was  further  attached  to  the  transverse  colon  by  strong 
adhesions,  in  which  were  found  several  large  blood-vessels  and 
some  lymphatic  glands  ;  two  of  the  latter  being  enlarged  and 
infiltrated  with  tubercle. 

A  part  of  the  omentum  was  attached  to  the  colon,  and 
in  it  the  veins  were  enormously  distended  and  much  con- 
voluted. They  were  full  of  air,  and  resembled  rather  the 
small  intestines  of  a  fowl  or  of  a  rabbit  than  the  blood-vessels 
of  a  human  being. 

On  examining  the  uterus  and  the  enormous  fibro-cystic 
tumour  which  was  springing  from  its  fundus,  the  vaginal  por- 
tion of  the  uterus  was  found  to  be  altogether  atrophied — the 


>  AND    UTERUS  495 

vagina  terminating  in  a  virginal  os  uteri ;  and  the  sensation 
conveyed  to  the  finger  was  that  of  a  very  light  movable  uterus. 
On  looking  for  the  body  of  womb,  its  place  was  found  to  be 
occupied  by  a  long  flexible  tube,  crackling  under  pressure,  like 
thick  parchment.  From  the  upper,  somewhat  dilated,  ex- 
tremity of  this  tube,  sprang  the  right  Fallopian  tube  and 
the  right  ovarian  ligament.  This  was  in  normal  relation  to 
the  right  ovary,  which  also  appeared  healthy.  The  vagina  and 
the  elongated  uterus  were  now  slit  open,  and  the  length  of  the 
entire  cavity  of  the  womb  was  found  to  be  7  inches,  that  of  the 
cervix  alone  3f  inches.  The  greatest  width  of  the  uterine 
cavity  was  close  to  the  fundus,  and  did  not  exceed  f  of  an  inch. 
The  left  Fallopian  tube  had  been  cut  through  half  an  inch  from 
its  uterine  extremity. 

The  walls  of  the  uterus,  like  the  Fallopian  tube,  were  of 
normal  thickness.  From  the  fundus  sprang  a  fibrous  column, 
5  inches  long,  3  inches  deep,  and  1^  inch  broad,  encircled  at 
its  upper  extremity  by  a  ligature.  The  left  side  of  this  fibrous 
column  presented  a  roughly  cut  surface,  5  inches  long  and  3 
inches  broad  or  deep,  being  the  point  at  which  the  tumour  first 
described  had  been  cut  through  at  the  operation.  The  tumour 
which  was  left  was  an  enormous  mass,  18  inches  in  length,  16 
inches  in  breadth,  and  near  its  centre  fully  7  inches  thick. 
The  lower  two-thirds  of  the  tumour  were  separated  by  a  deep 
sulcus  from  its  upper  third,  so  that  the  two  bodies  appeared 
distinctly  separate.  The  upper  tumour  was  11  inches  broad 
by  6  inches  long,  and  6  inches  in  depth ;  its  general  shape 
strongly  suggestive  of  an  enlarged  liver.  In  structure  the 
tumour  was  precisely  similar  to  the  one  removed  by  operation, 
and  described  by  Dr.  Eitchie. 

4  In  the  fourteenth  volume  of  the  "  Transactions  of  the 
Pathological  Society  of  London,"  p.  204,  may  be  found  a  short 
account  of  a  fibro-cystic  tumour  of  the  uterus  which  I  removed 
from  a  single  lady,  aged  fifty-three,  on  April  30,  1863.  '  One 
large  cyst  had  held  26  pints  of  fluid  and  4  pounds  of  fibrine; 
and  a  solid  mass,  which  weighed  more  than  16  pounds,  resem- 
bled very  closely  the  mass  just  described  by  Dr.  Eitchie.  The 
patient  sank,  from  shock,  four  hours  after  operation,  although 
the  tumour  was  completely  removed  ;  and  there  was  so  little 
difference  in  the  pedicle  from  that  often  seen  in  ovariotomy 


496  DIFFICULTY    OF   DIAGNOSIS 

that  it  was  not  until  after  post-mortem  examination  that  the 
true  nature  of  the  case  was  discovered.  Given,  a  large  semi- 
solid tumour,  fluctuating  in  some  parts,  containing  cysts 
holding  upwards  of  twenty  pints  of  fluid,  moving  beneath  the 
abdominal  wall,  the  uterus  being  movable,  and  not  enlarged 
so  far  as  measurement  by  the  sound  can  detect,  no  sound  or 
arterial  impulse  to  be  heard  which  is  not  often  heard  in  ovarian 
tumours,  and  no  history  of  haemorrhage  leading  to  a  suspicion 
of  uterine  disease — and  it  will  be  admitted  that  these  charac- 
ters of  the  two  fibro-cystic  tumours  of  the  uterus  which  I 
removed  so  closely  resemble  those  of  semi-solid  ovarian  tu- 
mours, that  diagnosis  must  be  very  uncertain.  Even  after  an 
exploratory  incision,  I  know  of  nothing  but  a  rather  darker — 
less  pearly  blue — aspect  of  the  tumour  which  would  put  the 
surgeon  on  bis  guard.  In  any  doubtful  case  it  would  be  well 
to  tap  the  largest  cyst  and  examine  the  fluid.  In  both  my 
cases  this  was  peculiar — not  the  viscid  mucoid  fluid  of  multi- 
locular  ovarian  cysts,  but  a  thin  serum,  with  five,  ten,  or  fifteen 
per  cent,  of  blood  intimately  mixed  with  it,  and  not  separating 
until  after  standing  for  some  hours.  In  this  way  I  have 
satisfied  myself,  in  at  least  four  cases,  that  tumours,  which 
others  considered  to  be  ovarian,  were  really  fibro-cystic  uterine 
growths.  If  the  operation  has  been  commenced,  and  the  dark 
aspect  of  the  tumour  is  observed,  it  would  certainly  be  ad- 
visable not  to  do  more  than  tap  one  or  more  of  the  largest 
cysts  before  examining  attentively  the  connections  between  the 
uterus  and  the  tumour.  If  these  should  prove  to  be  very 
intimate,  it  will  be  the  unpleasant  duty  of  the  surgeon  to 
desist  from  any  attempt  to  do  more,  and  to  close  the  wound  as 
soon  as  possible.' 

In  two  valuable  articles  on  '  Abdominal  Surgery '  in  the 
'  Boston  Medical  and  Surgical  Journal '  of  March  and  April  1881, 
the  removal  of  uterine  tumours  is  spoken  of  as  '  a  direct  out- 
growth from  ovariotomy,'  and  the  history  of  the  operation  is 
sketched  from  my  first  case  in  1861  to  the  present  time.  In 
1863,  my  experience  of  four  cases  led  me  to  the  conclusion 
that  '  it  would  only  be  under  most  unusual  circumstances  that 
I  would  again  remove  an  interstitial  fibrous  tumour  of  the 
uterus;  a  peritoneal  outgrowth,  or  an  ingrowth  towards  the 
uterine  cavity  and  vagina,  offering,  in  my  opinion,  far  more 


£ASE   OF  SUCCESSFUL   REMOVAL  497 

probability  of  successful  removal  than  an  interstitial  tumour.' 
Ten  years  later,  in  1873,  further  experience  had  brought  me 
to  the  opinion  quoted  by  the  Boston  reviewer,  that  '  when  a 
uterine  tumour  is  pedunculate,  or  can  be  separated  from  the 
principal  part  of  the  uterus,  or  when  the  whole  of  the  fundus 
and  body  of  the  uterus,  with  or  without  the  ovaries,  can  be 
removed,  leaving  the  cervix  and  its  vaginal  attachments  un- 
injured, the  operative  question  is  a  different  one,  and  recent 
experience  is  leading  to  a  more  encouraging  view  of  the  surgical 
treatment  in  such  cases.' 

After  five  years'  additional  work,  I  brought  the  surgical 
treatment  of  uterine  tumours  before  the  College  of  Surgeons 
in  the  Hunterian  Lectures,  giving  the  result  up  to  that  date  of 
all  my  operations  through  the  abdominal  wall,  amounting  to 
forty-five  cases.  Tables  of  these  cases  may  be  seen  in  the 
'  British  Medical  Journal '  of  July  27,  1878.  Very  shortly  after 
this  publication  I  printed  the  following  account  of  the  excision 
of  a  fibro-cystic  uterine  tumour.  On  July  24,  1878,  Mr.  Cowan 
of  Bath  wrote  to  ask  me  to  see  a  lady  who  was  leaving  for 
London  that  day,  in  order  to  consult  me  by  his  desire  and 
that  of  Dr.  Swayne  of  Clifton.  The  next  day  I  saw  this  lady, 
thirty-nine  years  of  age,  suffering  considerable  abdominal  pain 
and  difficulty  of  breathing  after  her  journey.  I  found  that 
she  had  been  married  four  years,  and  had  not  been  pregnant. 
The  catamenia  were  regular,  and  a  period  was  due.  She  was 
suffering  so  much  that  I  did  not  make  a  complete  examina- 
tion; and  the  next  day,  the  suffering  was  so  great  that  I 
tapped  a  large  cyst,  felt  between  the  umbilicus  and  the 
sternum,  and  removed  nineteen  pints  of  dark  fluid,  with  which 
(as  the  cyst  became  empty)  a  little  blood  was  mixed.  A  large 
semi-solid  tumour,  reaching  a  little  above  the  umbilical  level, 
was  then  felt,  and  a  harder  portion  was  found  in  the  right  iliac 
fossa,  which,  by  combined  external  and  internal  examination 
and  the  use  of  the  sound,  was  ascertained  to  be  the  uterus, 
high  up  and  to  the  right,  closely  connected  with  the  lower 
portion  of  the  tumour,  but  apparently  separable  the  one  from 
the  other. 

Mr.  Cowan  informed  me  that  the  illness  commenced  in  the 
summer  of  1876,  in  Italy,  whither  the  patient  had  gone  to 

K  K 


498  CASE    OF   SUCCESSFUL    REMOVAL 

recruit  after  great  mental  strain.  The  first  symptoms  were 
dull  pain  in  the  left  iliac  region,  with  a  sense  of  fulness,  pain 
on  pressure,  and  constipation,  followed  by  a  steady  increase  in 
size  till  February  1877,  when  he  (Mr.  Cowan)  found  '  fluctua- 
tion in  the  left  iliac  region,  and  a  solid  tumour  passing  down 
into  the  pelvis  anterior  to  the  uterus.'  There  was  steady  but 
slow  increase  until  October  1877,  when  sudden  painful  swelling 
of  the  left  leg  set  in,  with  acute  pain  in  the  left  groin.  After  a 
fortnight  this  subsided,  but  the  cyst  increased  more  rapidly, 
and  a  solid  mass  was  found  to  the  right  of  the  median  line  in  the 
umbilical  region.  Dyspnoea  and  general  distress  increased,  and 
walking  became  difficult. 

My  diagnosis  was  a  multilocular  ovarian  cyst,  displacing 
the  uterus  upwards  and  to  the  right.  This  was  confirmed  by 
an  examination  by  Mr.  Thornton  of  the  fluid  removed  by  tap- 
ping, who  reported  it  as  '  not  differing  in  any  way  from  ordinary 
ovarian  fluid,  except  the  blood,  which  is  fresh,  and  probably 
from  some  accidental  wound  of  a  vessel.  Now  the  blood  has 
settled,  it  looks  like  the  ordinary  "  linseed-tea  "  fluid,  and  the 
tests  and  microscope  confirm  its  ovarian  characters.' 

Great  relief  followed  the  tapping.  The  catamenia  came  on 
and  ceased  on  August  1.  But  the  fluid  began  to  collect  again 
and  some  interference  with  respiration  became  an  increasing 
trouble.  Dr.  Day  examined  the  chest  on  August  1 0,  and  found 
some  dulness  on  the  lower  part  of  the  left  lung,  which  he  attri- 
buted to  pressure.  We,  therefore,  decided  on  removal  of  the 
tumour. 

I  performed  the  operation  on  August  12,  under  spray  and 
with  strict  antiseptic  precautions,  assisted  by  Dr.  Bantock,  Dr. 
Woodham  Webb,  and  Mr.  Cowan  of  Bath,  Dr.  Day  administer- 
ing methylene.  By  an  incision,  five  inches  long,  in  the 
median  line  between  the  umbilicus  and  symphysis  pubis,  a 
very  thin  cyst  was  exposed.  It  was  bluish  in  appearance, 
like  the  peritoneum.  On  tapping  it,  reddish  serum  escaped. 
Extensive  adhesions  to  the  abdominal  wall  above,  and  to  the 
intestines  behind  and  to  the  left,  were  separated,  and  the 
empty  cyst  was  drawn  out  with  a  mass  of  solid  substance  at 
its  base.  I  then  found  that  both  ovaries  were  healthy  ;  that  the 
uterus  was  about  twice  the  normal  size,  irregularly  nodulated 
and  hardened ;  and  the  tumour  was  an  outgrowth  from  the 


*  REPORT   ON   TUMOUR  499 

back  part  of  the  fundus.  The  connecting  medium  or  pedicle 
was  fully  an  inch  in  length,  and  about  two  inches  in  breadth 
and  one  in  thickness.  I  secured  this  in  a  large  clamp  and 
divided  the  attachment.  Then  I  had  to  dissect  off  the  back  part 
of  the  tumour  from  the  sigmoid  flexure  of  the  colon  and  from 
the  rectum,  with  scissors.  In  doing  this,  I  accidentally  made 
an  opening  into  the  upper  part  of  the  rectum,  about  an  inch 
long,  but  sewed  it  up  immediately  with  an  uninterrupted 
suture,  carefully  sponged  out  the  peritoneal  and  pelvic  cavities, 
secured  several  bleeding  vessels  in  parts  where  adhesions 
had  been  separated,  and  closed  the  wound  by  silk  sutures 
around  the  clamp,  which  lay  at  the  lower  angle  of  the  closed 
wound. 

Dr.  Woodham  Webb  examined  the  tumour,  and  reported 
as  follows  :  '  Weight  of  solid,  two  pounds  and  a  quarter ;  fluid 
contents,  fourteen  pints.  The  tumour  was  an  outgrowth  from 
the  upper  and  back  part  of  the  uterus,  about  seven  inches  long, 
four  broad  at  its  widest  part,  and  at  one  point  two  inches  thick. 
It  was  of  a  flattened  lozenge-shape,  and  consisted  of  uterine 
tissue  very  slightly  changed  in  appearance.  It  was  surrounded 
by  three  large  cysts,  which  had  developed  on  its  surface,  two 
of  about  equal  size  and  one  not  more  than  half  that  of  the 
others — the  three  having  contained  fourteen  pints  of  a  red 
serous  fluid.  The  walls  of  the  three  cysts  were  thin,  with  a 
fine  layer  of  muscular  tissue,  spread  out  in  irregular  bundles 
between  the  two  serous  membranes—  the  peritoneum  and  the 
cyst  lining.  Inside  the  cysts,  on  the  solid  mass,  were  several 
ecchymosed  spots,  the  lining  membrane  being  detached  and 
giving  rise  to  small  secondary  cysts.  There  were  a  few  nodules 
of  fibrous  tissue  in  various  parts  of  the  cyst-walls.' 

The  progress  after  operation  was  one  of  uninterrupted 
recovery.  The  highest  temperature  was  100*2°;  the  most 
rapid  pulse,  108.  The  clamp  came  off  on  the  eighth  day.  The 
wound  above  the  clamp  healed  by  first  intention.  Thymol 
gauze  was  the  only  dressing  used. 

Writing  to  me,  December  5,  1878,  the  patient  says:  '  I  am 
wonderfully  well,  and  am  getting  back  my  walking  powers. 
I  have  not  felt  so  well  nor  in  such  spirits  for  years  past.'  She 
remains  quite  well  at  the  end  of  the  year  1881. 

K   K    2 


500  FIBROMA   MOLLUSCUM 

A  much  more  remarkable  case  was  that  of  a  lady  whom  I 
saw  in  consultation  with  Mr.  Symonds  of  Oxford  in  February 
1878.  She  was  single  and  thirty-six  years  of  age.  Her  abdo- 
men was  enormously  enlarged  by  a  solid  tumour,  which  extended 
upward  behind  the  lower  ribs  on  both  sides,  pressing  them  out- 
wards, and  passed  downwards  into  the  pelvis,  filling  up  the 
hollow  of  the  sacrum  and  causing  prolapsus  of  the  posterior  wall 
of  the  vagina.  There  was  considerable  oedema  of  the  feet  and 
legs,  which  was  said  to  disappear  for  a  time  after  the  cessation 
of  each  monthly  period.  The  cervix  uteri  could  not  be  reached, 
and  it  was  impossible  to  ascertain  where  the  uterus  was  situated. 
The  catamenia  were  regular  in  time  and  normal  in  quantity. 
Mr.  Symonds  had  advised  removal  of  the  tumour  in  1876  when 
it  was  much  smaller,  but  the  patient  and  her  friends  steadily 
objected.  The  first  symptom  of  illness  was  in  1868,  when 
backache  became  troublesome,  and  soon  after  a  small  tumour 
was  discovered  in  the  left  side  of  the  abdomen.  The  growth 
went  on  slowly  for  some  years,  but  in  1877  was  much  more 
rapid.  When  the  patient  came  under  our  observation  in 
February  1877, 1  expressed  my  opinion  to  Mr.  Symonds  that,  as 
the  tumour  was  quite  solid,  not  fluctuating,  and  as  the  uterus 
could  not  be  found,  an  accurate  diagnosis  was  impossible,  and 
that  only  an  exploratory  incision  could  determine  as  to  the 
possibility  of  removal.  I  thought  the  tumour  more  likely 
to  be  uterine  than  ovarian,  and  probably  some  such  rare 
form  of  abdominal  fibroma  as  I  had  once  removed  in  Grer- 
many,  and  which  has  been  described  by  Virchow  as  fibroma 
molluscum,  not  necessarily  connected  with  either  uterus 
or  ovaries.  The  decision  as  to  operation  being  left  to  the 
patient,  she  at  first  declined,  but  suffering  became  daily 
greater,  and  it  was  arranged  that  I  should  make  an  exploratory 
incision  on  March  7,  four  days  after  the  cessation  of  the 
catamenia. 

The  sketch  on  the  next  page,  although  made  of  another 
patient,  gives  an  excellent  idea  of  the  appearance  of  this  lady 
at  the  time,  except  that  it  hardly  shows  how  much  the  tumour 
encroached  on  the  thorax,  and  not  at  all  the  oedema  of  the 
legs. 

Mr.  Symonds  and  Mr.  Hill  being  present,  my  incision  was 
made  in  the  median  line  between  the  umbilicus  and  pubes,  and 


EXCISION   OF   TUMOUR  WEIGHING   SEVENTY   POUNDS         501 

I  cut  into  the  substance  of  a  solid  tumour  which  was  closely 
adherent  to  the  abdominal  wall.  After  separating  some  ad- 
hesions, I  passed  my  hand  into  the  peritoneal  cavity  and  found 
the  tumour  to  be  free  from  adhesions  on  the  left  side,  also  be- 
hind and  above,  but  to  be  closely  bound  down  on  the  right  side. 
In  front,  the  bladder  was  so  high  that  the  incision  could  not  be 
carried  within  about  four  to  five  inches  of  the  pubes.  So  it 
was  extended  upwards,  about  five  or  six  inches  above  the 
umbilicus,  as  soon  as  I  had  convinced  myself  that  it  would 
be  possible  to  remove  the  tumour.  A  large  piece  of  adhering 
omentum  was  detached  from  the  upper  part  and  behind.  To- 
wards the  left  side  a  broad  mesenteric  attachment  was  divided 
by  the  knife,  large  vessels  being  temporarily  secured  by  torsion- 
forceps.     I  was  then  able  to  shell  out  the  tumour  from  a  sort 


of  vascular  capsule,  formed  by  two  layers  of  the  right  broad 
ligament,  and  separate  it,  but  only  by  the  knife,  from  the  pos- 
terior surface  of  a  uterus  of  normal  size,  after  forcibly  pulling 
the  tumour  up  out  of  the  pelvis  and  separating  it  from  the  rec- 
tum, to  which  it  adhered  closely.  The  right  ovary  (although 
normal)  was  cut  away  because  the  Fallopian  tube  had  been 
divided  and  the  broad  ligament  was  much  torn.  The  left 
ovary  and  Fallopian  tube  were  not  disturbed.  Several  silk 
ligatures  were  applied  to  the  right  of  the  uterus,  and  also  to 
open  vessels  on  its  posterior  surface  where  the  tumour  had 
been  cut  away.  Two  large  pieces  of  omentum  were  cut  oft 
after  securing  them  by  ligature.  I  then  found  that  the  two 
opposite  sides  of  the  remnant  of  the  capsule  of  the  broad 
ligament  (out  of  which  I  had  enucleated  the  tumour)  could  be 


502         EXCISION   OF   TUMOUR   WEIGHING   SEVENTY   POUNDS 

brought  together  behind  the  uterus,  so  as  to  complete  the  union 
of  the  divided  peritoneum  from  the  lower  angle  of  the  opening 
in  the  abdominal  wall,  over  the  elevated  bladder  and  the  fundus 
uteri,  all  down  the  back  of  the  uterus  to  the  rectum.  I  did  this 
by  an  uninterrupted  suture  of  fine  silk,  making  about  twenty 
points  of  suture,  and  finishing  close  to  the  vagina  and  rectum. 
In  this  way  the  peritoneal  sac  was  completely  shut  off  from 
the  torn  cellular  tissue  of  the  pelvis.  A  good  deal  of  sponging 
was  necessary  to  remove  clots  of  blood  from  the  peritoneal 
cavity;  but  very  little  blood  was  lost  considering  the  great 
size  of  the  tumour  and  the  extent  of  its  attachments.  The 
opening  in  the  abdominal  wall  was  closed  by  twenty- 
five  silk  sutures.  The  patient  was  placed  in  bed  exactly 
an  hour  from  the  minute  when  she  began  to  inhale  methy- 
lene. She  was  faint  and  very  chilly,  a  spray  of  a  solution 
of  thymol  (1  in  1,000  of  water)  having  played  upon  the 
abdomen  all  through  the  operation ;  and,  although  sponges 
moistened  with  warm  thymol  solution  protected  the  abdominal 
cavity  to  some  extent,  the  chilling  effect  of  the  spray  was 
manifest. 

Upon  examining  the  tumour  it  was  found  that  about  two 
pounds  of  blood  had  drained  from  the  vessels  divided  in  its 
capsule,  and  at  its  line  of  separation  from  the  uterus.  Its 
circumference,  in  three  different  directions,  was  52  inches 
at  the  smallest,  57  inches  at  the  largest,  and  53  inches  in  a 
third.  A  small  piece  was  cut  out  for  microscopical  examina- 
tion, and  the  tumour  was  then  weighed  in  the  museum  of  the 
Middlesex  Hospital,  and  found  to  be  68  lbs.  6  oz.  The  tumour 
was  '  chiefly  composed  of  cells  with  relatively  large  nuclei,  many 
containing  several  nucleoli  of  the  type  difficult  to  distinguish 
as  distinctly  muscular ;  but  in  some  parts  of  the  tumour  un- 
striped  muscle-cells  were  manifest.'  (J.  K.  Thornton.)  I  have 
very  little  to  add  as  to  the  progress  after  operation,  except 
that  the  temperature  seldom  rose  above  99°,  only  reaching 
101  '2°  (the  highest  noted)  once.  Only  four  opiates  were 
given.  There  was  never  any  distension  of  the  abdomen. 
Six  days  after  operation,  the  bandage  and  dressing  were 
removed  for  the  first  time.  The  four  or  five  layers  of  thymol 
gauze  next  the  skin  were  damp  with  serum ;  the  outer  layers 
were  quite  dry.     The  wound  was  united  from  top  to  bottom. 


MODIFICATIONS   IN   OPERATIVE   PROCEDURE  503 

All  the  twenty-five  sutures  were  removed,  and  the  line 
of  union  was  almost  imperceptible.  The  dressing  was  only- 
changed  twice  after  this  ;  and,  except  a  few  drops  of  pus  from 
one  of  the  central  stitchholes,  union  was  perfect  by  first 
intention. 

For  a  few  days  in  the  second  and  third  week  after  opera- 
tion the  patient  occasionally  vomited,  and  was  weak  and  low- 
spirited,  and  there  was  a  considerable  swelling  in  the  pelvis,  as 
if  from  a  hematocele  in  front  of  the  rectum,  to  such  an  extent 
that  the  uterus  could  not  be  felt.  There  were  frequent  very 
offensive  watery  motions,  but  never  any  purulent  discharge. 
When  the  swelling  in  the  pelvis  began  to  subside,  and  after 
washing  out  the  rectum  with  thymol  solution,  rapid  amend- 
ment set  in  and  went  on.  Two  days  before  she  left  London  by 
rail  for  Oxford,  on  April  8,  just  a  month  after  operation,  I 
carefully  examined  the  pelvis  by  vagina  and  rectum,  and  really 
could  not  find  any  trace  of  an  operation  having  been  per- 
formed. The  uterus  was  in  its  normal  position,  was  movable, 
and  of  ordinary  size  and  weight.  She  wrote  herself  in  May, 
saying  *  I  am  able  to  walk  a  little,  and  get  out  in  the  air 
as  much  as  possible.'  But  improvement  did  not  continue  ;  a 
pelvic  abscess  formed,  which  was  not  opened,  and  she  died  in 
August. 

In  the  two  years  which  followed,  I  adopted  two  important 
modifications  in  the  operative  procedure — first,  the  more 
complete  use  of  antiseptic  precautions ;  and,  secondly,  the 
union  by  suture  of  the  peritoneal  edges  of  the  divided  uterine 
wall.  I  also  contrived  better  pressure-forceps  for  securing 
divided  blood-vessels  before  tying.  In  the  paper  read  at  the 
Cambridge  meeting  of  the  British  Medical  Association,  in 
August  1880,  and  published  in  the  Journal  of  the  Association, 
September  4,  1880,  I  said,  'Whatever  doubt  some  may  enter- 
tain as  to  the  value  of  my  experiments  on  animals,  and  practice 
on  women,  in  leading  most  operators  in  the  present  day  to 
bring  divided  edges  of  peritoneum  together  whenever  they  have 
been  separated  by  wound  or  by  operation,  I  myself  have  no 
doubt  whatever  about  it ;  and  just  as  strongly  as  I  assert  that 
it  is,  and  must  be,  better,  when  the  abdominal  wall  is  divided, 
to  bring  the  peritoneal  edges  and  surfaces  of  the  opening 
together,   restoring   the   complete   closure    of    (he    peritoneal 


504  CASE   OF  CYSTIC   UTERINE   TUMOUR 

cavity,  than  to  leave  the  cavity  free  to  the  admission  of  fluids 
oozing  from  wounded  muscle,  fat,  and  cellular  tissue,  and  to 
allow  contact  of  intestine  and  omentum  with  anything  more 
than  peritoneum  ;  so  strongly — more  strongly  if  I  could — would 
I  insist  that  the  peritoneal  edges  of  the  divided  uterine  wall, 
or  of  the  connecting  part  of  the  outgrowth  with  the  uterine 
wall,  should  also  be  carefully  brought  together  ...  by  many 
sutures,  or  by  uninterrupted  suture  along  the  whole  extent  of 
the  gap.'  In  concluding  that  paper,  I  alluded  to  a  case  then 
under  observation,  which  I  brought  forward  partly  to  illustrate 
the  advantage  of  completely  uniting  by  suture  the  divided  edges 
of  the  peritoneal  wall,  and  partly  to  argue  that,  when  the 
uterine  cavity  has  been  opened,  it  is  better  not  to  close  the 
mucous  surfaces  also  by  sutures,  after  the  method  of  Schroder, 
as  the  opening  left  for  some  oozing  of  blood  through  the  vagina 
may  sometimes  be  useful.  A  few  more  details  of  this  case  may 
be  now  given. 

On  June  9,  1880,  I  saw  a  married  lady,  aged  62,  in  con- 
sultation with  Dr.  Richard  Smith,  of  Haverstock  Hill,  who  had 
been  called  in  about  a  fortnight  before,  on  account  of  uterine 
haemorrhage.  This,  after  twelve  years'  absence,  had  come  on 
at  the  end  of  1879,  and  had  recurred  since  every  three  weeks, 
lasting  one  week.  She  had  consulted  an  obstetric  physician 
four  years  before,  who  said  that  there  was  '  ovarian  enlarge- 
ment.' She  had  been  married  twice,  had  one  child  by  her  first 
husband,  twenty-nine  years  ago,  and  had  never  been  pregnant 
since.  With  the  return  of  the  uterine  haemorrhage,  there 
occurred  enlargement  of  the  abdomen,  which  increased  rapidly, 
loss  of  flesh,  shortness  of  breath,  and  very  obstinate  constipa- 
tion. The  girth  of  the  abdomen  at  the  most  prominent  part 
was  42  inches.  The  uterine  cavity  only  measured  2f  inches, 
but  the  cervix  moved  in  all  directions  with  a  large  semi-solid 
tumour,  which  filled  the  whole  abdomen  quite  up  to  the  ensi- 
form  cartilage.  I  removed  the  tumour  on  July  21,  1880,  cut- 
ting away  nearly  all  the  supravaginal  portion  of  the  uterus,  and 
after  tying  all  bleeding  vessels  carefully,  sewing  together  the 
peritoneal  edges  of  the  divided  uterine  wall.  For  about  three 
days  afterwards  a  little  bleeding  went  on  through  the  vagina, 
but  the  patient  recovered  without  any  febrile  elevation  of  tem- 
perature, was  in  excellent  health  in  1881,  and  so  remains.     The 


CASE   OF   EXCISION   OF   UTERINE   FIBROID  505 

doubt  as  to  the  tumour  being  ovarian  was  accounted  for  by  the 
fact  that  a  large  cyst-like  cavity  in  the  centre  of  the  tumour 
contained  thirteen  pints  of  bloody  fluid,  while  the  solid  portion 
weighed  only  a  little  more  than  two  pounds.  I  am  much 
indebted  to  Dr.  K.  Smith  for  his  assistance  at  this  operation, 
and  for  his  care  of  the  patient  afterwards,  as  she  remained 
in  his  charge  during  my  absence  from  London. 

In  this  and  previous  cases,  I  had  been  content  with  the 
pressure-forceps  described  and  figured  in  the  '  British  Medical 
Journal,'  vol.  i.,  1879,  p.  928  ;  but,  feeling  the  want  of  more 
effectual  means  of  securing  bleeding  vessels  before  dividing 
them,  I  had  forceps  made  similar  in  form,  but  with  longer 
handles,  and  a  compressing  surface  more  than  an  inch  in 
length.  With  several  pairs  of  such  forceps,  applied  before  any 
tissues  are  cut  through,  large  tumours  may  be  cut  away  with 
only  very  small  loss  of  blood.  They  were  used  with  excellent 
effect  in  the  following  case. 

On  September  27,  1880,  assisted  by  Mr.  Thornton  and  Mr. 
A.  Doran,  I  removed  a  large  solid  uterine  fibro-myoma  from  a 
single  lady,  aged  41.  By  an  incision  eight  inches  long,  the 
tumour  was  exposed,  or  rather  the  omentum,  containing  very 
large  veins,  which  covered  the  tumour  and  adhered  to  it.  Two 
ligatures  were  applied  to  the  omentum,  which  was  then  divided 
between  them.  Some  adhesions  to  the  abdominal  wall  were 
then  separated,  and  the  tumour  turned  out  entire.  It  was  an 
outgrowth  from  the  left  side  of  the  fundus  uteri.  The  band  of 
connection  between  the  uterus  and  the  outgrowth  was  between 
two  and  three  inches  in  length,  and  about  one  inch  in  breadth. 
This  was  first  compressed  and  held  by  two  of  the  large  forceps 
just  described,  and  the  tumour  was  cut  away.  Then  a  large 
needle  and  double  thread  was  pushed  through  the  uterine  tissue 
behind  the  forceps,  and  each  thread  was  tied  as  the  forceps 
were  taken  off.  Lastly,  the  peritoneal  edges  of  the  divided 
uterine  wall  were  brought  together  by  #n  uninterrupted  suture 
of  fine  carbolized  silk.  After  the  removal  of  the  tumour,  the 
rest  of  the  uterus  appeared  to  be  quite  normal  in  size  and  con- 
sistence. Both  ovaries  were  healthy.  Kecovery  went  on  with- 
out fever — the  highest  temperature  was  100-2°.  There  was 
unusual  nervous  irritability  during  convalescence,  perhaps  ex- 
plained by  the  facts  that  her  father  and  an  uncle  had  both 


506  CASE   OF   EXCISION    OF   UTERINE   FIBROID 

been  insane,  and  attempted  suicide  ;  but  she  went  away  thirty 
days  after  operation,  in  a  very  good  state  of  health,  and  has 
since  been  quite  well.  Mr.  Doran  described  the  tumour  as  a 
solid  uterine  fibro-myoma,  weighing  between  seven  and  eight 
pounds. 

The  tumour  in  the  following  case  was  very  much  larger, 
and  the  patient  in  a  state  of  the  utmost  distress  from  its  weight 
and  pressure.  It  was  a  solid  fibro-myoma,  which  weighed 
twenty-five  pounds,  after  all  blood  and  serum  had  drained  from 
it.  I  removed  it  on  October  7,  1880,  assisted  by  Mr.  Thornton, 
Mr.  Vevers  of  Hereford,  and  Mr.  Qrton  of  Foleshill,  near 
Coventry.  The  incision  was  eight  inches  long.  Three  to  four 
pints  of  clear  fluid  escaped  on  dividing  the  peritoneum.  A 
nodular  solid  tumour  was  covered  by  vascular  adherent  omen- 
tum. This  was  tied  and  divided.  There  was  no  pedicle.  The 
growth  was  a  prolongation,  or  irregular  enlargement,  of  the 
fundus  uteri.  After  fixing  each  end  of  the  narrowest  part  of 
the  neck  of  the  growth  by  pressure-forceps,  I  amputated  the 
fundus  just  beyond  the  forceps,  opening  the  uterine  cavity  at 
the  posterior  part  of  the  growth.  Six  portions  of  uterine  tissue 
were  tied,  after  three  transfixions,  with  double  silk  ligatures,  as 
the  forceps  were  removed,  and  several  large  vessels  were  also 
tied  separately.  The  peritoneal  coat  of  the  uterus  was  then 
united  by  a  line  of  uninterrupted  suture,  so  as  to  cover  up  the 
divided  uterine  tissue.  The  line  of  union  measured  between 
three  and  four  inches.  More  than  a  pint  of  blood  was  lost.  I 
made  no  note  of  the  state  of  the  ovaries.  The  patient  was 
extremely  weak  for  a  fortnight  after  the  operation ;  but  she 
went  to  Coventry  at  the  end  of  a  month,  and  she  called  on  me 
in  May  1881,  in  excellent  health.  I  could  detect  nothing  by 
abdominal  or  pelvic  examination,  except  the  linear  cicatrix  in 
the  abdominal  wall,  to  show  that  any  operation  had  been 
performed.  The  catamenia  are  quite  regular,  and  had 
only  been  excessive  for  the  two  or  three  periods  just  after 
the  operation. 

I  had  seen  this  patient  several  times  during  the  six  years 
from  the  discovery  of  the  tumour  till  the  operation,  and  had  at 
first  dissuaded  her  from  any  interference,  on  account  of  a  strong 
vascular  thrill  always  felt  in  the  left  side  of  the  vaginal  wall. 
It  was  not  till  ascitic  iluid  formed,  and  the  tumour  became 


REMOVAL  OF  UTERINE  TUMOUR  507 

more  mobile,  that  I  agreed  to  operate.  The  vascular  thrill  was 
explained  by  omentum  adherent  to  the  lower  part  of  the  tumour, 
and  containing  very  large  blood-vessels. 

The  next  case  is  also  one  of  almost  unexpected,  but  com- 
plete, recovery.  In  May  1876,  a  married  lady,  aged  38,  called 
on  me  with  a  letter  from  Dr.  Birch  of  Hazaribagh,  in  India, 
under  whose  care  she  had  been  since  May  1875.  She  was 
married  in  1871,  went  to  India  in  the  same  year,  had  never 
been  pregnant,  but  remained  in  good  health  until  she  suffered 
from  fever  in  September  1874.  In  February  1875,  Dr.  Ewart 
of  Calcutta  discovered  an  abdominal  swelling  which  he  thought 
might  possibly  be  early  pregnancy,  although  there  had  been  no 
irregularity  in  menstruation.  The  swelling  increased  rapidly 
in  1875,  and,  when  I  saw  her  in  May  1876  the  uterus  was 
evidently  enlarged  to  the  size  in  the  fifth  or  sixth  month  of 
pregnancy.  As  there  were  no  urgent  symptoms,  she  returned 
to  India,  and  I  did  not  see  her  again  until  May  1877.  There 
had  been  some  slight  increase  in  the  size  of  the  uterus,  and 
menstruation  was  becoming  rather  profuse ;  but  she  remained 
in  fairly  good  health  till  July  1878,  when  her  general  health 
suffered  after  much  anxiety  and  over-exertion ;  but  she  got 
over  this,  and  went  through  1879  pretty  well.  In  June  1880 
the  tumour  having  considerably  increased  in  size,  Sir  W.  Jenner 
saw  her  with  me  in  consultation  as  to  the  question  of  operation, 
and  it  was  decided  that  there  should  be  further  delay,  but  that 
the  tumour  should  be  removed  as  soon  as  it  became  intolerable. 
Menstruation  became  still  more  profuse,  size  increased,  she 
lost  flesh,  became  unable  to  take  any  but  very  short  walks,  the 
feet  swelled,  and  purpuric  spots  appeared  on  the  legs.  In 
December  1880,  at  another  consultation  with  Sir  W.  Jenner, 
we  found  a  large  solid  tumour,  reaching  quite  up  to  the  ensi- 
form  cartilage,  and  an  ovary  could  be  felt  and  moved  in  each 
iliac  region.  The  uterine  cavity  was  slightly  elongated,  but  I 
thought  the  tumour  and  part  of  the  fundus  uteri  might  pro- 
bably be  removed  without  opening  this  cavity.  It  was  agreed 
that  I  should  attempt  to  remove  the  tumour  ;  but  that,  if  the 
difficulty  proved  to  be  greater  than  I  expected,  I  should  then 
remove  both  ovaries  in  the  hope  of  thus  leading  to  atrophic 
change  in  the  tumour.  We  waited  until  after  the  cessation  of 
another  menstrual  period,  and  1  then  went  into  Gloucestershire, 


508     REMOVAL  OF  UTERINE  TUMOUR  AND  LEFT  OVARY 

and  operated  on  February  12th,  1881,  assisted  by  Dr.  Forty 
and  Mr.  Simmons  of  Wotton-under-Edge,  Mr.  Wickham  of 
Tetbury,  and  Mr.  A.  Grace  of  Sodbury.  Dr.  Day  administered 
methylene.  After  making  an  incision  from  two  inches  above 
to  six  inches  below  the  umbilicus  in  the  median  line,  the 
enlarged  solid  uterus  was  exposed,  free  from  adhesions,  but 
covered  by  very  large  veins,  and  there  was  no  distinct  neck  to 
the  tumour  or  fundus.  The  left,  ovary  was  large,  and  both  were 
easily  separable  from  the  tumour.  My  first  intention,  accord- 
ingly, was  to  be  satisfied  with  removal  of  both  ovaries,  and 
leave  the  uterus  alone.  On  drawing  up  the  left  ovary,  a  cyst, 
or  corpus  rubrum,  in  it  burst,  and  much  black  clot  was  pressed 
out.  I  then  transfixed,  tied  the  connecting  tissues  between  the 
ovary  and  the  enlarged  uterus,  and  cut  the  ovary  away.  Very 
free  bleeding  followed,  and  successive  ligatures  cut  through  a 
soft  venous  plexus.  I  therefore  felt  compelled  to  remove  the 
tumour,  and,  after  applying  on  each  side,  before  and  behind, 
four  pairs  of  large  pressure-forceps,  I  amputated  the  tumour, 
cutting  through  the  fundus  uteri  diagonally  from  the  right 
Fallopian  tube,  downwards  and  to  the  left  of  the  bleeding  sur- 
face, where  the  left  ovary  had  been  attached.  The  uterine 
cavity  was  not  opened.  Part  of  the  fundus  and  the  body  left 
with  the  cervix  were  normal  in  size  and  consistence.  The  left 
Fallopian  tube  was  removed  with  the  tumour.  The  right 
remained ;  and  the  right  ovary,  although  rather  large,  was  not 
disturbed.  Theoretically,  it  would  have  been  better  to  remove 
it ;  but  I  was  very  unwilling  to  prolong  a  serious  operation  by 
anything  not  absolutely  necessary.  Several  very  large  arteries 
and  veins  were  secured,  some  by  ordinary  ligature  of  carbolized 
silk,  some  by  ligature  after  transfixing  the  uterine  tissue ;  and 
then  the  peritoneal  edges  of  the  divided  fundus  were  brought 
together  by  suture.  Although  a  great  deal  of  blood  was  lost, 
the  lips  never  lost  their  colour,  and  there  was  no  vomiting. 
The  patient  was  exactly  an  hour  under  the  influence  of  the 
anaesthetic,  and  Dr.  Day  told  me  that  he  had  never  given  so 
much  methylene  before  at  any  of  my  operations.  Nearly  two 
ounces  were  used.  I  did  not  make  any  provision  for  drainage, 
as  I  had  carefully  sponged  away  all  blood  and  clot ;  and  the 
wound  was  united  in  the  usual  way  by  silk  sutures.  Phenolized 
spray  was  used,  phenolized  sponges,  ligatures,  and  instruments, 


REMOVAL  OF  UTERINE  TUMOUR  AND  RIGHT  OVARY    509 

and  dry  dressing.  The  tumour  was  a  solid  fibroma,  with  several 
projections  or  outgrowths  from  the  peritoneal  surface.  It 
weighed  11^  lbs. 

The  patient  was  left  in  charge  of  Dr.  Forty  of  Wotton- 
uncler-Edge,  and  recovery  was  uninterrupted  by  any  bad 
symptom.  The  temperature  reached  101°,  and  the  pulse  104, 
on  the  third  day ;  but  the  convalescence  may  be  said  to  have 
been  without  fever.  I  saw  the  lady  in  London  on  April  28th, 
quite  well,  and  with  nothing  but  the  linear  cicatrix  in  the 
abdominal  wall  to  be  detected  as  showing  that  there  had  ever 
been  any  disease  of  the  uterus.  The  cervix  was  mobile,  and 
nothing  abnormal  could  be  discovered  anywhere.  The  catamenia 
appeared  quite  as  usual  the  first  week  in  May,  after  an  interval 
of  three  months,  and  passed  off  quite  normally.  The  lady 
called  on  me  in  London  in  November  1881  in  excellent 
health,  menstruating  regularly,  and  with  no  sign  of  having 
undergone  any  operation  except  the  cicatrix  in  the  abdominal 
wall. 

In  the  following  case,  operated  on  June  27,  1881,  the 
operation  might  have  been  described  in  exactly  the  same  terms, 
except  that  the  left  ovary  was  left  with  the  remnant  of  the 
uterus  in  this  case,  while  the  right  ovary  was  left  untouched  in 
the  preceding  case.  Both  may  be  described  as  supra- vaginal 
amputation  of  the  uterus  with  removal  of  an  ovary.  The  lady 
was  a  widow,  52  years  of  age,  but  still  menstruating  regularly 
and  profusely,  mother  of  four  children,  the  youngest  of  whom 
is  26  years  old.  She  was  sent  to  me  by  Dr.  Kidd  on  account 
of  severe  flooding  at  every  monthly  period,  which  went  on  to 
faintness,  and  was  followed  by  extreme  exhaustion.  Sir  W. 
.Tenner  saw  her  with  me ;  and,  on  the  risk  of  the  operation  for 
the  removal  of  the  large  uterine  tumour  being  explained  to  her, 
she  decided  to  wait.  She  went  to  Switzerland,  and  almost  died 
at  Berne  from  most  alarming  haemorrhage.  As  soon  as  she 
was  able  to  travel  she  returned  to  England,  determined  to 
submit  to  the  operation  which  I  have  already  alluded  to.  The 
recovery  was  uninterrupted  except  by  a  very  troublesome  irrita- 
tion of  the  bladder.  She  was  obliged  to  travel  to  Davos-Platz 
in  October  1881  with  an  invalid  relative,  and  although  she 
suffered  at  first  from  living  at  such  an  elevation,  she  wrote  to 
me  on  December  15,  1881,  saying,  'The  pain  in  the  bladder 


510  CASES   OF   PARTIAL   REMOVAL 

scarcely  gives  me  any  trouble,  and  I  have  seen  nothing  at  the 
monthly  periods.'  Indeed,  the  only  inconvenience  arising  from 
the  operation  is  the  necessity  for  wearing  a  belt  in  consequence 
of  the  threatening  of  a  ventral  hernia  at  a  weak  part  of  the 
cicatrix  in  the  abdominal  wall. 

In  one  other  case  of  removal  from  a  married  lady  35  years  of 
age,  of  a  large,  solid  uterine  fibroma,  weighing  between  fifteen 
and  sixteen  pounds,  and  which  had  been  surrounded  by  ascitic 
fluid,  I  have  to  record  an  almost  sudden  death  from  shock  and 
haemorrhage.  The  patient  died  a  few  minutes  after  being  placed 
in  bed.  No  very  great  amount  of  blood  was  lost,  but  the  patient 
took  methylene  very  badly,  and  I  think  she  was  injuriously 
affected  by  the  cooling  influence  of  the  spray.  Beyond  this  there 
was  nothing  in  the  operative  procedure  which  differed  from 
the  cases  of  the  patients  of  Dr.  Forty  and  Mr.  Vevers  just 
described. 

These  are  all  the  cases  in  which  I  have  removed  uterine 
tumours  entirely  since  August  1880,  and  all  but  this  last  have 
recovered  in  the  most  satisfactory  manner.  In  three  other  cases 
I  made  simple  exploratory  incisions ;  doing  nothing  more,  as 
the  difficulties  of  removal  appeared  very  great.  One  patient  died 
a  week  after  the  incision,  of  peritonitis.  The  other  two  were 
neither  better  nor  worse  for  the  incision.  In  another  case,  a 
patient  of  Dr.  Andrews  of  Hampstead,  a  single  lady,  aged  60,  I 
was  only  able  to  remove  part  of  a  fibroma,  after  emptying  a 
large  cyst-like  cavity.  The  patient  died  on  the  third  day. 
And  in  one  other  case,  a  patient  of  Dr.  Monro  of  Newtown, 
Montgomeryshire,  where  I  could  only  remove  a  projecting  out- 
growth from  the  main  part  of  the  tumour,  the  patient,  who  was 
in  an  extremely  feeble  condition  before  the  operation,  died  on  the 
eighth  day.  One  lady,  a  patient  of  Mr.  Laurence  of  Chepstow, 
Dr.  Bond  of  Shrewsbury,  and  Sir  W.  Jenner,  recovered  and  has 
remained  in  good  health  after  the  emptying  of  a  large  uterine 
cyst  of  blood-clot. 

I  feel  very  hopeful  that,  by  the  use  of  the  improved  pres- 
sure-forceps, the  arrest  of  haemorrhage  will  be  effected  much 
more  easily  and  completely  than  before;  that  suture  of  the 
uterine  wall  will  obviate  more  than  one  source  of  danger ;  and 
that,  by  careful  attention  to  all  needful  antiseptic  precautions, 
the  removal  of  uterine  tumours  may  henceforth  be  undertaken 


>  REMOVAL  OF  UTERINE  TUMOUR  511 

with  a  far  more  confident  expectation  of  a  successful  result 
than  could  have  been  reasonably  entertained  a  very  few  years 
ago. 

All  the  cases  in  which  I  have  removed,  or  attempted  to 
remove,  uterine  tumours  are  arranged  in  the  following  tables. 
The  first  contains  particulars  of  39  cases  of  removal,  the  second 
31  cases  of  partial  removal  or  of  exploratory  incision. 


512 


Table  I. — Cases  of 


Medical  Attendant 


Professor  Pirrie,  Aberdeen 

Dr.  Sim,  Naples    . 
Mr.  Ellis,  Sloane  Street 


Samaritan  Hospital 


Dr.  MacMurty,  West  Brom 
wich 

Dr.  Puller      . 


Dr.  Brandt,  Oporto 
M.  Nelaton,  Paris 
Dr.  Protheroe  Smith     . 
Dr.  Conrad,  Berlin 
Dr.  Boberts,  Bliyl 
Mr.  Soper,  Dartmouth  . 
Sir  W.  Jenner,  Bart.    . 
Dr.  Schantz,  Witten     . 
Dr.  Schonfeld,  Labes    . 

Mr.  Peck,  Talding 
Dr.  Playfair  . 
Dr.  Kidd,  Dublin  . 
Dr.  Neild,  Plymouth    . 
Dr.  Jack,  Hampton  Court 
Dr.  Day .... 
Dr.  Freeborn,  Oxford    . 
Dr.  Hetley,  Norwood    . 

Dr.  Symonds,  Oxford    . 


Date 

of 

Operation 

Age 

1861  Oct. 

33 

1863  Jan. 

35 

„    April 

53 

18G8  April 

40 

1869  April 

36 

„    May 

37 

1870  June 

36 

1871  June 

46 

1872  Jan. 

38 

„    March 

44 

„    May 

36 

1874  April 

33 

„    Dec. 

32 

1875  May 

40 

„    May 

40 

1876  April 

37 

,.    Aug. 

49 

„    Oct. 

36 

„    Nov. 

40 

1877  March 

49 

„    April 

52 

,,    July 

56 

„    July 

50 

1878  March 

36 

Condition 


Married 

Single 
Single 


Married 

Single 
Married 

Single 

Married 

Single 

Single 

Married 

Married 

Single 

Single 

Widow 

Single 
Single 
Single 
Single 
Single 
Single 
Single 
Single 

Single 


Adhesions 


None 

None . 

Omental  and  parietal  . 

Omental  and  mesenteric    . 

Parietal 

None 

Omental 

None 

None 

None 

Notes  defective 

Omental 

None 

Omental 

None 

Omental  and  parietal . 

None 

None 

Peritoneal,  omental,  mesenteric,  and 
intestinal 

Parietal 

None 

None 

None 

Parietal,  mesenteric,  and  omental     . 


513 


Removal  of  Uterine  Tumours. 


Treatment 

of 

Pedicle 

Weight  and 
nature  of 
Tumour 

Length 

of 
Incision 

Result 

Subsequent  History 

or  Cause  of 

Death 

No. 

Ligature      brought 
out  of  the  wound 

Fundus  and  body  of  uterus, 
27  lbs. ;  both  ovaries  re- 
moved 

inches 
10 

Died    4    days 
afterwards 

Exhaustion 

1 

No  pedicle ;  tumour 
enucleated 

17  lbs.,  solid ;  fibroid  intra- 
mural 

6 

Died     in      4 
hours 

Haemorrhage  and  chloro- 
form 

- 

Ligature  brought  out 
through  the  wound 

Fibroid  cystic  outgrowth 
from  fundus ;    solid,   16 
lbs.;    26  pints   fluid;    4 
lbs.  clot  in  cyst ;    right 
ovary  adherent,  and  re- 
moved with  tumour 

9 

Death    in    3 
hours 

Shock ;  chloroform  (?) 

3 

Ligature  returned  . 

Fibroid  size  of  cocoa-nut 

5 

Died  44  hours 
after  opera- 
tion 

Peritonitis 

4 

Acupressure    . 

Solid  tumour,  34  lbs.  10  ozs. 

11 

Died    in     40 
hours 

Peritonitis 

5 

Ligature  . 

Fundus  and  body  of  uterus 
removed 

5 

Recovered 

Died    6    months    after- 
wards   of    cancer    of 
cervix 

G 

Pin    and    ligature ; 
extra-  peritoneal 

Solid  myoma,  22  lbs. 

Died,  14th  day 

Pyaamic  pleurisy 

7 

Pin    and   ligature ; 
extra-peritoneal 

11  lbs.  11   ozs.,  solid;   59 
pints  peritoneal  fluid 

11 

Recovered 

Well  in  1881 

8 

Ligature  returned  . 

20  lbs. ;    fibroid  removed 
with  left  ovary 

8 

Died,  3rd  day 

Peritonitis 

9 

Pin  and  ligature 

Uterus  and  both  ovaries, 
26  lbs. 

10 

Died  in  2  hours 

Haemorrhage 

10 

Notes  defective 

Uterine  fibroid  and  right 
ovary  removed 

? 

Died 

Suppurative  peritonitis 

11 

Clamp 

Fibroid  myoma,  Hi  lbs.  ; 
right  ovary 

8 

Recovered 

Well  June  1878 

12 

Ligature  returned  . 

Fibroid  myoma,  9  lbs. 

8 

Died     in    40 
hours 

Haemorrhage 

13 

Clamp 

Fibro-cystic   uterine    and 
right  ovary,  19  lbs. 

6 

Recovered 

Well  in  1878 

14 

Ligature  and  drain- 
age 

Clamp 

Fibroma  molluscum  cvsti- 
cum,  29  los.,  and  right 
ovary 

Sub-peritoneal  outgrowth 
from  fundus 

6 

7 

Recovered 
Recovered 

Well  in  1881 

Well  in  1878.    Tumour 
in  Museum 

15 

16 

Clamp 

Large  uterine  fibroid  and 
both  ovaries 

9 

Died,  5th  day 

Pneumonia 

17 

Ligature  returned  . 

Fibroid  sub-peritoneal  re- 
moved 

4 

Recovered 

Well  in  1881 

18 

Ligature  returned  . 

Fibro-cystic  ;     two    out- 
growths, 2£  lbs. 

6 

Died,  4th  day 

Peritonitis 

19 

Clamp 

Fibro-cystic,  20  lbs.  ;  and 
left  ovary 

6 

Died    in    20 

hours 

20 

Ligature  returned  . 

Two    fibroid    outgrowths 
removed ;  4  lbs.  4  ozs. 

6 

Recovered 

21 

Ligature  returned  . 

Solid    fibroid     outgrowth 
from  fundus,  5  Ids. 

6 

Died,  6th  day 

Septic  peritonitis 

22 

Needle  and  ecraeeur 
chain  ;  extra-peri- 
toneal 

Uterine    fibroid,    12    lbs., 
and  botli  ovaries 

8 

Died,  3rd  day 

Septic  peritonitis 

23 

Ligatun  s  returned . 

Fibro-cellular,  70  lbs. 

16 

Recovered 

Died    5    months    after- 
wards of  pelvic  abscess 

24 

I,  L 


514 


Table  I. — Cases  of  Removal 


Medical  Attendant 


Date 

of 

Operation 


35 


Mr.  Larkins  .... 

Mr.  Cowan,  Bath  . 

Mr.  Cribb       . 

Mr.  Wheelhouse,  Leeds 

Mr.  Stretton,  Kidderminster 

Mr.  Pearse,  Camelford  . 
Dr.  Iterson,  Gouda,  Holland 

Dr.  Pratt,  Paris     . 
Mr.  Lock,  Tenby  . 


Dr.  B.   Smith,  Haverstock 
Hill 

Dr.  Attenburrow,  Jersey 


Dr.  Orton,  Coventry 


Dr.  Birch,  Hazaribagh,  India 


1878  June 
»    Aug. 

„    Dec. 

1879  Feb. 

„     Aug. 

„    Oct. 
„    Oct. 


Age 


„    Dec.        30 


1880  Jan. 


Dr  Kidd . 
Dr.  Webb 


„    June 


Sept. 


Oct. 


1881  Feb. 


June 


Nov. 


Condition 


Single 

Married 

Married 
Married 

Single 

Married 
Married 

Single 


Married 


Single 


Married 


Married 


Widow 
Married 


Abdominal  wall  and  intestines 

Omental  and  intestinal 

Ovary  (right)  adherent  to  tumour 

None 

Parietal,  omental,  and  intestinal 

None 

None 

None 

Abdominal  wall  and  omentum  . 

Omentum 

None 

None 

Omental 


515 


of  Uterine  Tumours — continued. 


Treatment 

of 

Pedicle 

Weight  and 
Nature  of 
Tumour 

Length 

of 
Incision 

Result 

Subsequent  History 

or  Cause  of 

Death 

No. 
25 

Transfixion         and 
tying,     including 
Fallopian  tube 

12  lbs. ;  solid  fibroid 

inches 
8  to  9 

Died,  4th  day 

Hemorrhage  and  peri- 
tonitis 

Clamp 

Cystic     outgrowth    from 
fundus,  2^  lbs.,  contain- 
ing 14  pints 

5 

Recovered 

Well  in  1881 

26 

Ligatures 

Amputation  of  all  supra- 
vaginal portion  of  uterus 

6 

Died  same  day 

Hsemorrhage 

27 

Transfixed  and  tied 

Large    solid     fibroid    on 
fundus  of  the  uterus,  base 
2  inches  wide 

7 

Died,  3rd  day 

Peritonitis 

28 

Transfixed  and  tied. 
Several  vessels  liga- 
tured separately 

Solid  fibroid  of  uterus,  29 
inches  in  circumference. 
Ovary  attached  and  re- 
moved 

7 

Recovered 

Well  in  1881 

29 

Forceps    and   liga- 
ture 

Fibroid   outgrowth   from 
uterus  with  pedicle 

6 

Recovered 

Well  in  1881 

30 

Cyst      cut      away. 
Ligatures  on  stump 
of  fibroid 

Fibro-cystic  of  uterus,  26 
lbs. 

6 

Recovered 

Well  in  1881 

31 

Came  away  on  tying 
ligature.     Second 
ligature    and    su- 
tures 

Fibroid  outgrowth    from 
uterus 

4 

Recovered 

Left  London  a    nionth 
after  operation.    Well 
in  18  SI 

32 

Enucleated.       Ves- 
sels tied.     Perito- 
neum  sewn    over 
bare  surface 

Two  fibroid    tumours  on 
the  fundus  of  uterus,  one 
softening 

6 

Died,  3rd  day 

Peritonitis 

33 

Vessels  tied.     Peri- 
toneum sewn  over 
stump 

Fibro-cystic  of  uterus 

6 

Recovered 

Well  in  1881 

34 

Pedicle  compressed, 
tied,    and    perito- 
neum   sewn    over 
cut  surface 

Solid        uterine        fibro- 
myoma,  between  8   and 
9  lbs. 

8 

Recovered 

Well  in  1881 

35 

No  pedicle.    Ampu- 
tation  of  fundus. 
Peritoneum    sewn 
over      amputated 
part 

Solid      fibro-myoma      of 
uterus 

8 

Recovered 

Well  in  May  1881 

36 

No  pedicle.    Upper 
part     of     uterus, 
left     ovary,     and 
Fallopian  tube  cut 
away.     Peritoneal 
cut     edges    sewn 
together 

Enlarged     solid     uterus, 
fibroid  with  outgrowths, 
11J  lbs. 

8 

Recovered 

Well  Feb.  1882 

37 

Ligatures   and    su- 
tures 

Fibroid    enlargement    of 
fundus,  9  lbs. ;  removed 
with  left  ovary 

8 

Recovered 

Well  October  1881 

38 

Ligatures 

Fibro-myoma     uteri,     IS 
lbs. 

8 

Died 

Almost        immediately 
after  operation.  Shock 
and  haemorrhage 

39 

L   L   2 


516 


Table  II. — Cases  of  Exploratory  Incision  and  Partial 


No. 
1 

Medical  Attendant 

Date 
of 

Operation 

Age 

Condition 

Dr.  Shorthouse,  Carshalton     .... 

1863  April 

33 

Single 

2 

1864  June 

45 

Single 

3 

Samaritan  Hospital  ...... 

1866  Dec. 

39 

Married 

4 

Dr.  Churchill,  Dublin 

1867  Aug. 

48 

Married 

5 

Dr.  Garrod,  London 

1868  Feb. 

53 

AVidow 

6 

Dr.  Arthur  Farre 

1869  Jan. 

42 

Married   ■ 

7 

Mr.  Turner,  Hereford 

„    Nov. 

25 

Ma'xied 

8 

Mr.  Marsden 

1870  June 

33 

Married 

9 

Dr.  Whitehead,  Manchester    .... 

„    Dec. 

35 

Single 

10 

Dr.  Wane 

1871  Aug. 

63 

Married 

11 

Dr.  De  la  Camp,  Hamburg       .... 

1873  April 

36 

Married 

12 

Dr.  Philpot 

!,    J»ly 

30 

Single 

13 

Dr.  Gason,  Eome 

1875  May 

31 

Single 

14 

Dr.  Hodgson,  Hornsea 

1876  June 

33 

Married 

15 

Dr.  Thursfield,  Leamington     .... 

„    June 

35 

Married 

1« 

Dr.  Hall  Davis 

„    Sept. 

34 

Widow 

17 

Dr.  Arthur  Farre 

„    Oct. 

46 

Married 

18 

Mr.  Sweeting,  King's  Lynn      .... 

„    Nov. 

38 

Married 

19 

Dr.  Whitehead,  Manchester     .... 

1878  Feb. 

41 

Married 

20 

Mr.  Claremont,  Hampstead  Road    . 

„    May 

42 

Single 

21 

Dr.  Regensburger,  San  Francisco   . 

„    Oct. 

42 

Married 

22 

Mr.  Goddard 

„    Nov. 

45 

Married 

23 

Mr.  Lunn,  Hull 

1879  May 

41 

Married 

24 

Dr.  Latham,  Cambridge 

„    Oct. 

40 

Single 

25 

Mr.  Laurence,  Chepstow 

1880  Feb. 

42 

Married 

26 

Dr.  Andrews,  Hampstead 

„    Oct. 

60 

Single 

27 

Mr.  Vevers,  Hereford 

„    Oct. 

52 

Single 

28 

Mr.  Heslop,  Birmingham 

„    Oct. 

40 

Single 

29 

Dr.  Hill,  Lymington 

„    Oct. 

50 

Single 

30 

Dr.  Monro,  Newtown,  Montgomeryshire 

1881  Feb. 

40 

Married 

31 

„    March 

36 

Married 

517 


Removal  of  Fibro-cystic  Tumours  of  the  Uterus. 


Adhesions  and  character 

of 

Tumour 


None  ;  solid  tumour  punctured  ; 
no  fluid 

To  intestines  and  omentum  ;  30 
pints  of  ascitic  fluid,  13  pints  of 
cystic  fluid,  and  20  lbs.  fibroid 
tumour  removed 

Ascitic  fluid  removed;  solid  uterine 
tumour  punctured 

Uterine  fibroid  punctured 

Parietal  ;  fibro-cystic  tumour 
punctured,  8  pints  purulent  fluid 
removed 

Large  uterine  fibroid  not  disturbed 

Ascitic  fluid  only  removed ;  fibroid 
tumour  not  disturbed 

Incision  only 

None  ;  incision  only 

None ;  ascitic  fluid  removed  ; 
uterine  cyst  tapped 

None  ;  ascitic  fluid  only  removed  . 

Parietal ;  incision  only  . 

Incision  only 

None  ;  cyst  tapped  and  emptied  ; 
solid  fibroid  not  disturbed 

Incision  only 

Incision ;  ascitic  fluid ;  fibroid 
tumour  untouched 

Fibro-cystic  uterine  drained ; 
parietal  and  omental 

Incision  only 

Incision ;  removal  of  nodule  .        . 

Incision  only 

Incision  only 

Uterine  cyst  drained 

Incision  only 

Solid  fibro-myoma  not  disturbed   . 

Intestinal ;  no  pedicle  ;  blood  cyst 
drained 

IncisioD  ;  tapping  of  cyst  and  re- 
moval of  part  of  fibroma  of  uterus 

Simple  incision ;  uterine  vein 
wounded 

Simple  incision        .... 

Simple  incision         .... 

Incision  and  removal  of  projecting 
outgrowth  from  main  part  of 
fibroma  of  uterus 

Incision  only  ;  bladder  wounded 


Incision 


No  note 


4  inches 

4  „ 

5  ,. 
5      „ 


Result 


Left  hospital 
10th  day 

Death    in    3 
hours 


Suppuration 
and  relief 


Recovered 
Recovered 

Recovered 
Recovered 
Died 

Recovered 
Recovered 
Recovered 
Recovered 

Recovered 
Recovered 

Recovered 

Recovered; 
Recovered 
Recovered 
Recovered 
Recovered' 
Recovered 
Recovered 
Recovered 

Died,  3rd  day 

Died,  7th  day 

Recovered 
Recovered 
Died,  8th  day 


Subsequent  History 

or  Cause  of 

Death 


Died  16  months  after  operation ; 
the  tumour  then  -a  eighed  25  lbs. ; 
had  34  pints  of  fluid  around  it 

Hemorrhage  ;  portion  of  tumour 
not  removed,  18  inches  in  length 
and  7  in  thickness  ;  not  weighed. 
A  second  tumour,  11  in.  broad,  6 
in.  long,  and  6  in.  deep 

Died  some  months  afterwards 
Patient  died  in  1871 


Remained  well  two  years,  but  died 
in  1872 


In  fairly  good  health,  1881 

Died  two  years  afterwards,  1872 

Alive  in  1878 

Fifteen  days  after  operation 

Died  in  187? 
Well  in  1877 
Well  in  1878 
Well  in  1878 

Died  of  diphtheria  in  Feb.  1878 
Died  inl  878 

Died  in  1881..   Albunienuria 


Well  in  June  1878 
Died  July  IT,  1878 
Well  in  1881 
Died  in  1881 
Well  in  1881 
Well  in  1881 
Wall  in  1881 

Peritonitis 

Peritonitis 

Neither  better  nor  worae  for  incision 

Neither  better  nor  worse  for  incision 

In  extremely  feeble  condition  be- 
fore operation 

Well  in  October  1881 


518  PARTIAL   AMPUTATION   AND 


CHAPTER   XVIII. 

ON   PARTIAL   AMPUTATION  AND   ON   COMPLETE   EXCISION   OF 
THE   UTERUS. 

The  removal  of  fibroid  tumours  of  the  uterus  and  the  partial 
amputation  of  the  hypertrophied  uterus,  have  led  on  to  its  more 
or  less  complete  extirpation  in  cases  of  uterine  cancer.  The 
names  of  Blundell  and  Freund  are  associated  with  these  opera- 
tions. More  recently  Porro  has  supplemented  the  Caesarean 
section  by  the  removal  of  the  entire  uterus  except  the  vaginal 
portion,  which  is  left  after  amputation  at  about  the  division 
between  the  neck  and  the  body  of  the  organ.  The  case  which 
I  am  about  to  describe  is  not  identical  with  any  of  these  pro- 
ceedings. It  was  not  a  supra-vaginal  amputation,  but  a  com- 
plete taking  away  of  the  whole  gravid  uterus  and  its  appen- 
dages. Even  if  I  had  followed  Porro's  example  it  would  have 
been  the  first  case  of  the  kind  in  Great  Britain.  But  cutting 
round  the  neck  into  the  vagina  and  leaving  no  stump  makes 
my  operation  not  only  the  first  excision  of  the  gravid  uterus  in 
this  country,  but  one  unique  in  its  mode  of  performance,  com- 
pleteness, and  success. 

The  case  was  that  of  a  farmer's  wife,  37  years  of  age, 
pregnant  six  months  with  her  sixth  child,  and  suffering  from 
epithelioma  of  the  cervix  uteri.  She  was  brought  to  me  for 
consultation  at  my  house  by  Dr.  Goldsworthy  Tucker,  of 
Farningham,  on  October  5,  1881.  She  had  borne  a  child 
sixteen  months  previously,  had  nursed  it  for  three  months, 
became  weak  and  troubled  with  vaginal  discharge,  but  again 
became  pregnant,  and  aborted  at  six  weeks,  towards  the  end 
of  1880;  again  menstruated  in  March,  April,  and  May  1881. 
The  exact  date  of  the  last  conception  is  doubtful,  but  the 
calculation  must  be  made  from  the  month  of  May.  At  her  first 
visit  to  me  she  was  quite  conscious  of  the  movements  of  the 


COMPLETE   EXCISION   OF   THE   UTERUS  519 

child,  ballottement  was  distinct,  and  I  could  hear  the  sounds  of 
the  foetal  heart.  The  cervix  uteri  was  long  and  enlarged,  the  os 
admitting  one  finger  easily  for  one  inch,  and  the  cervical  canal 
was  surrounded  by  a  mass  of  epithelioma,  which  everted  the 
lips  of  the  os  and  projected  downwards  into  the  vagina.  Pro- 
posals for  the  inducing  of  premature  labour  and  for  the  removal 
of  the  diseased  cervix  had  already  been  discussed  in  other 
consultations  with  Dr.  Playfair ;  but  it  seemed  to  me  that  the 
disease  was  so  distinctly  limited  to  the  cervix  that  if  all  the 
morbid  tissue  were  scraped  away  and  chloride  of  zinc  applied  to 
the  denuded  surface,  pregnancy  might  go  on  to  the  full  term. 
And  this  procedure  was  decided  upon.  A  few  days  more,  how- 
ever, reduced  the  patient  to  such  a  state  of  pain  and  weakness, 
with  great  increase  of  the  discharge,  that  we  were  called  to  re- 
view with  Dr.  Graily  Hewitt  the  various  objections  and  advan- 
tages of  the  different  courses  open  to  us.  Our  deliberations 
ended  in  the  decision  that  it  would  be  better  to  remove  the 
whole  uterus  and  its  contents,  and  I  accordingly  performed  the 
operation  on  October  21,  with  the  assistance  of  Mr.  Thornton 
and  Mr.  Doran ;  Dr.  Graily  Hewitt,  Dr.  Tucker,  and  Mr.  Cadge 
of  Norwich  being  present. 

The  patient  was  secured  as  for  ovariotomy ;  but,  as  it  was 
necessary  to  keep  a  catheter  in  the  bladder,  an  opening  was 
made  expressly  for  it  in  the  waterproof  covering.  The  vagina 
was  plugged  with  thymol  cotton,  wetted  with  warm  water  con- 
taining about  1  per  cent,  of  phenol.  I  divided  the  abdominal 
wall  in  the  middle  line  to  an  extent  of  about  eight  inches,  from 
two  inches  above  to  six  inches  below  the  umbilicus.  The  uterus 
thus  exposed  was  about  the  size  of  a  large  adult  head.  After 
turning  it  out  I  inserted  four  sutures  in  the  upper  part  of  the 
wound  over  a  large  flat  sponge,  so  as  to  keep  back  the  intestines 
and  protect  the  abdomen  from  needless  cooling  by  the  spray. 
I  found  the  ovaries  at  a  higher  level  and  nearer  to  the  fundus 
than  was  expected,  and  it  was  quite  easy  to  secure  the  sper- 
matic artery,  first  on  the  left  and  then  on  the  right  side,  by 
transfixing  the  broad  ligament  below  each  ovary  and  tying  with 
strong  silk.  I  took  the  catheter  as  my  guide  in  dissecting  the 
bladder  from  the  anterior  surface  of  the  uterus.  The  ex- 
panded uterine  coats  were  very  thin,  like  a  tense  cyst,  and  they 
were  soon  accidentally  ruptured.     I  punctured  the  protruding 


520  CASE   OF   COMPLETE   EXCISION 

membranes  and  a  quantity  of  liquor  amnii  escaped.  The  next 
thing  was  to  draw  out  the  foetus,  and  tie  and  cut  the  cord  ;  but 
I  did  not  interfere  with  the  placenta.  I  then  separated  the 
attachments  between  uterus  and  vagina,  completely  circumcising 
the  neck,  and  securing  by  pressure-forceps  all  bleeding  vessels 
as  they  were  divided.  The  entire  uterus,  with  all  the  diseased 
parts  about  the  os  and  cervix,  was  thus  removed.  The  forceps 
were  then  taken  off  successively,  and  every  bleeding  vessel  tied 
with  carbolized  silk.  Then,  taking  out  the  vaginal  plugs,  I 
brought  together  the  opening  into  the  vagina,  and  the  edges 
of  the  divided  broad  ligaments,  with  silk  sutures.  The  pelvis 
was  carefully  cleansed,  the  wound  closed  as  usual  with  silk 
sutures,  and  the  ordinary  dressing  applied  as  after  ovariotomy. 

The  patient  was  under  the  influence  of  methylene  for  about 
75  minutes,  but  the  operation  from  beginning  the  incision  to 
closing  the  wound  was  completed  within  an  hour. 

Mr.  Cadge  kindly  noted  the  time  occupied  by  the  different 
stages  of  the  operation  as  follows  : — 

2.35  p.m.  Patient  began  to  inhale  methylene. 

2.41    „     Catheter  and  plugging  vagina. 

2.50   „     Incision  in  abdominal  wall. 

2.53    „     Uterus  drawn  out. 

2.56  „  Sutures  in  upper  part  of  abdominal  wall,  dividing 
broad  ligaments  and  vagina,  removing  foetus 
and  securing  vessels,  till 

3.10    „     Uterus  removed. 

3.40  „  Ligature  of  vessels  and  sutures  of  vagina  and 
broad  ligaments. 

3.50   „     Closing  of  wound  and  dressing. 

3.55    „     Patient  in  bed. 

The  uterus  has  been  preserved  in  the  Museum  of  the  Eoyal 
College  of  Surgeons,  and  the  accompanying  drawings  are  back 
and  front  views  of  the  preparation. 

The  first  of  these  drawings  shows  the  posterior  aspect  of  the 
entire  uterus  and  ovaries  as  they  were  removed.  The  shred 
of  peritoneum  seen  hanging  near  the  central  part  of  the  diseased 
cervix  was  stripped  from  the  anterior  surface  of  the  rectum. 

The  second  drawing  is  a  view  of  the  anterior  surface, 
showing  where  the  peritoneal  covering  of  the  uterus  was 
divided,  just  where  it  is  reflected  on  to  the  bladder.     Just 


OF   THE   GEAVID   UTERUS 


521 


below  the  line  of  divided  peritoneum  a  darker  line  shows  the 
opening  into  the  uterine  cavity  through  which  the  foetus  was 
drawn  out.  Below,  in  both  drawings,  the  cervix  altered  by 
epithelioma  is  very  well  depicted. 

Mr.  Doran  reported  that  the  uterus  and  its  appendages, 
when  removed,  '  weighed  twenty-five  ounces  exclusive  of  the 
foetus,  and  measured  six  inches  in  length.' 


*  The  upper  part  of  the  uterus  presented  no  abnormal  ap- 
pearance ;  anteriorly,  immediately  below  the  line  of  reflexion 
of  the  peritoneum  on  to  the  bladder,  was  a  perfectly  horizontal 
lacerated  wound,  about  two  inches  in  width,  opening  into  the 
uterine  cavity.  The  cut  ends  of  the  uterine  artery  could  be 
seen,  on  each  side,  entering  the  uterus  at  its  lateral  and  inferior 
part,  between  the  anterior  and  posterior  peritoneal  coverings. 
The  os  was  completely  encircled  by  a  cauliflower  growth  which 
extended  very  little  into  the  uterine  cavity,  but  invaded  the 
cellular   tissue    to   the  right  of  the   cervix.     The   portion  of 


522 


CONDITION    OF   PATIENT 


vaginal  wall  removed  formed  a  complete  but  very  narrow 
fringe  round  the  new  formation.  This  growth,  when  examined 
microscopically  by  Mr.  Eve  and  myself,  showed  all  the  charac- 
teristics of  epithelioma.  The  right  ovary  contained  a  large 
corpus  luteum  of  pregnancy,  the  left  showed  two  corpora  lutea 
in  process  of  atrophy ;  the  stroma  of  both  was  normal  and  free 
from  dilated  follicles. 


'  The  foetus  weighed  twenty-two  and  a  half  ounces,  two  and 
a  half  ounces  lighter  than  the  uterus  and  its  appendages  ;  it 
measured  eleven  inches  and  was  ill-nourished,  its  body  covered 
with  a  fine  down,  its  eyelids  gummed  together,  and  its  nails  not 
extending  to  the  tips  of  the  fingers  ;  the  cord  was  nine  and  a 
half  inches  in  length.  The  conclusion  would  be  that  it  was 
about  a  week  over  the  sixth  month  after  conception.' 

The  condition  of  the  patient  after  the  operation  was  pretty 
much  what  we  see  in  cases  of  ovariotomy ;  rather  more  pain 
and  sickness  than  in  a  simple  case,  but  the  shock  and  symptoms 


♦  AFTER    OPERATION  523 

less  urgent  than  in  very  complicated  cases.  Three  small 
opiates  were  given  within  six  hours  after  the  operation. 
Sickness  remained  troublesome  during  the  first  week,  and  the 
patient  was  nourished  with  injections  of  beef  tea  and  port 
wine,  with  a  little  laudanum  occasionally.  The  highest  tem- 
perature was  101*2°,  and  the  most  rapid  pulse  128.  During 
the  night  between  the  28th  and  29th,  eight  days  after  the 
operation,  an  untoward  opening  of  the  wound  happened  from 
frequent  vomiting,  but  the  stitches  were  carefully  replaced  by 
Mr.  Thornton  in  my  absence,  and,  though  the  temperature 
rose  soon  after  a  degree  higher  than  it  had  been,  the  sickness 
ceased  in  the  afternoon. 

After  this,  though .  some  of  the  stitches  once  more  cut 
through,  and  the  patient  was  kept  in  a  state  of  irritation  by  an 
accidental  scald  on  the  leg  by  a  hot-water  cushion,  there  was 
not  much  to  remark  beyond  a  rather  free  discharge  of  serum 
from  the  vagina,  which  afterwards  became  purulent,  and  ceased 
within  the  third  week.  Twenty-eight  days  after  operation  she 
was  moved  into  another  room,  but  before  this  the  pulse,  tem- 
perature and  digestive  functions  had  been  quite  normal.  Urine 
passed  freely ;  she  had  neither  pain  nor  sickness  and  she  slept 
well.  She  returned  to  her  home  in  Kent,  by  road,  on  November 
21.  When  asked  in  what  respect  this  confinement  differed 
from  those  of  her  five  children,  she  said  she  had  always  suffered 
from  vomiting,  but  more  this  time  than  ever  before ;  that  the 
chief  difference  was  that  she  had  no  trouble  this  time  with  her 
breasts,  and  that  the  most  pain  was  from  the  scald  on  her 
leg.  Her  husband  called  on  me  in  the  first  week  of  1882 
and  told  me  that  she  was  in  good  health,  gaining  strength, 
enjoying  life,  and  had  no  vaginal  discharge,  pain,  or  irritation. 
This  case  then  distinctly  proves  that  a  patient  may  recover 
after  complete  excision  of  a  gravid  uterus  and  both  ovaries, 
and  Mr.  Doran's  inspection  and  report  of  the  specimen  in  the 
College  Museum  encouraged  us  to  expect  that  as  the  diseased 
part  had  been  completely  removed,  as  it  often  is  in  cases  of 
epithelioma  of  the  lip  or  anus,  where  many  years  often  elapse 
without  any  new  morbid  growth,  there  might  be  at  least  a  con- 
siderable prolongation  of  life,  and  to  be  hopeful  that  the  patient 
might  escape  a  recurrence  of  the  disease.  But  she  came  up 
to  see  me  three  times  at  intervals  of  a  fortnight  in  February 


524  PROPOSED   MODIFICATIONS 

and  March  1882,  with  a  very  suspicious  thickening  of  the 
vaginal  cicatrix,  although  the  general  health  was  steadily- 
improving. 

If  I  were  to  repeat  the  operation  I  should  modify  its  suc- 
cessive steps  according  to  the  gravid  or  non-gravid  state  of 
the  cancerous  uterus.  When  non-gravid,  recent  experience 
serves  to  prove  that  extirpation  by  the  vagina  is  the  safer 
method.  When  gravid,  it  is  possible  that  dilatation  of  the 
cervix  and  emptying  the  uterine  cavity  as  a  preliminary 
measure  might  still  enable  the  operator  to  act  through  the 
vagina.  No  case  so  treated,  as  far  as  my  knowledge  goes,  has 
been  recorded,  and  it  is  not  easy  to  estimate  the  amount  of 
risk  which  would  have  to  be  encountered.  It  seems  probable 
that  in  nearly  all  cases  of  gravid  cancerous  uterus,  either  the 
abdominal,  or  a  combined  vaginal  and  abdominal,  operation 
would  afford  the  greatest  chance  of  success.  In  either  case  a 
large  elastic  catheter  or  a  canula,  through  the  end  of  which 
diverging  wires  expand,  like,  but  shorter  than,  those  figured  on 
page  169,  would  serve  as  a  guide  and  safeguard- in  separating  the 
uterus  from  the  bladder;  and  if  the  abdominal  operation  should 
be  selected,  a  large  ring  pessary,  or  a  modified  Zwancke's  pessary, 
in  the  vagina,  would  afford  better  help  in  making  the  section 
of  the  vaginal  wall  round  the  neck  of  the  uterus  than  the 
cotton  plugs  which  I  used.  Of  course  the  vagina  ought  to  be 
thoroughly  cleansed  by  sulphurous  acid  or  some  other  disin- 
fectant. 

The  position  of  the  patient  during  the  abdominal  operation 
should  be  the  same  as  for  ovariotomy,  but  for  a  combined 
vaginal  and  abdominal  operation  it  would  be  convenient  to 
separate  the  thighs  and  flex  the  legs,  carefully  protecting  them 
from  cold.  In  any  case  a  strong  reflecting  lamp  should  be 
provided  and  ready  for  use — say,  for  example,  a  good  carriage 
lamp  or  a  policeman's  bull's-eye,  until  a  cool,  glowing  electric 
light  is  perfected,  such  as  we  shall  probably  soon  obtain  by 
means  of  the  Faure  accumulator,  and  one  of  the  incandescent 
lamps  of  Swan  or  Edison.  Something  of  this  kind,  particularly 
if  the  spray  be  used,  would  aid  greatly  when  vessels  are  being 
tied  or  sutures  passed,  unless  the  light  in  the  room  is  unusually 
strong. 

The  length  of  the  incision  in  the  abdominal  wall  need  not 


,       OF   THE    OPERATION  525 

be  so  long  as  that  which  I  made,  if,  after  exposing  the  uterus, 
the  liquor  amnii  were  evacuated  by  a  trocar.  The  uterus 
would  still  further  be  diminished  in  size  by  dividing  its  wall  and 
removing  the  fetus,  but  it  would  be  very  desirable  to  avoid 
any  interference  with  the  placenta.  In  Porro's  supra-vaginal 
amputation  an  elastic  ligature  passed  round  just  above  the 
vagina  might  be  tried  with  advantage,  but  of  course  is  out  of 
the  question  if  the  cervix  has  to  be  removed. 

After  withdrawing  the  uterus  from  the  abdominal  cavity  a 
few  sutures  should  be  inserted  so  as  to  bring  together  the  edges 
of  the  upper  part  of  the  opening  in  the  abdominal  wall,  and 
close  it  over  a  flat  sponge.  This  prevents  the  intestines  from 
escaping  and  protects  them  from  the  cooling  of  the  spray  when 
it  is  used.  I  do  not  think  I  need  say  more  about  the  suppres- 
sion of  haemorrhage  by  tying  the  spermatic  arteries  or  the  use 
of  pressure-forceps  than  will  be  found  in  my  narrative  of  the 
case.  By  careful  dissection,  and  the  guide  of  a  catheter, 
the  uterus  may  be  separated  from  the  bladder  without  much 
danger,  but  I  do  not  yet  see  any  mode  of  certainly  providing 
against  the  mischance  of  tying  or  dividing  one  or  both  ureters. 
I  fear  that  with  all  possible  care  it  is  an  accident  which  may 
occasionally  prove  unavoidable. 

Mr.  Nunn  suggested  to  me  last  year  that  removal  of  the 
entire  uterus  would  be  more  easy  if  the  organ  were  first  divided 
into  two  parts  by  cutting  it  through  in  the  median  line  and 
removing  first  one  side  and  then  the  other.  He  founded  this 
proposal  on  his  anatomical  observations  brought  before  the 
Pathological  Society  in  1857,  and  published  in  the  ninth  volume 
of  the  '  Transactions.'  Professor  Miiller,  of  Berne,  has  more 
recently  made  a  similar  recommendation,  as  a  modification  of 
total  extirpation  of  the  uterus  by  the  vagina.  He  has  not 
carried  his  proposal  into  practice,  but  he  thinks  that  the  neces- 
sary ligatures  would  be  more  easily  applied  and  be  much  less 
likely  to  slip  if,  after  drawing  down  the  uterus,  it  can  be  '  split 
into  two  symmetrical  halves  in  a  vertical  direction.  Then  each 
half  of  the  uterus  with  its  ligament  could  be  drawn  backwards,' 
the  ligatures  applied,  and  the  uterus  cut  away  ('  Centralblatt 
fur  Gynakologie,'  1882,  No.  8). 

When  the  abdominal  operation  is  performed,  my  own 
present  feeling  is  in  favour  of  the   intra-peritoneal  method  of 


526  PRACTICAL   SUGGESTIONS 

securing  the  vessels,  vrith  suture  of  the  peritoneal  edges,  and 
complete  closure  of  the  incision  in  the  abdominal  wall.  Olshau- 
sen's  recent  experience  with  the  elastic  ligature,  proving  that 
the  ligature  and  the  parts  compressed  by  it  may  be  left  within 
the  abdominal  cavity  with  most  encouraging  results,  strengthens 
my  impression  in  favour  of  the  intra-peritoneal  ligature.  But 
I  freely  admit,  at  the  same  time,  that  recent  cases  by  Dr. 
Bantock,  Mr.  Thornton,  and  Mr.  Meredith  prove  that  the  extra* 
peritoneal  treatment  of  the  pedicle,  or  of  the  root  of  outgrowths 
from  the  uterus,  or  portions  of  the  uterus  included  in  a  ligature 
or  compressing  wire,  may  be  very  safely  and  successfully  effected 
by  Kceberle's  serre-nceud,  which  is  used  as  a  clamp,  prevented 
from  being  drawn  inwards  by  two  strong  pins  passed  through 
close  to  the  wire  loop,  and  the  edges  of  the  wound  then  carefully 
closed  around  the  stump. 

Most  operators  have  thought  it  necessary  to  arrange  for 
drainage  after  separating  the  uterus  from  its  vaginal  attach- 
ments all  round.  But  I  do  not  see  that  drainage  can  be  more 
necessary  in  this  operation  than  after  the  removal  of  uterine 
or  ovarian  tumours,  where  I,  at  least,  have  almost  completely 
abandoned  it.  I  believe  it  to  be  more  important  effectually  to 
close  the  opening  between  the  peritoneal  cavity  and  the  vagina 
by  sutures,  than  to  keep  up  a  sinus  by  a  drainage  tube.  Indeed, 
I  should  very  much  fear  that  the  latter  course  would  be 
hazardous.  It  has  also  been  proposed  to  use  two  sets  of  sutures, 
one  for  the  vaginal  mucous  membrane  and  one  for  the  peri- 
toneum and  broad  ligaments.  My  present  feeling  is  that  the 
vaginal  sutures  are  unnecessary,  and  may  possibly  be  injurious 
by  leading  to  collections  of  blood  or  serum  in  the  pelvic 
cellular  tissue. 

As  I  have  never  performed  a  combined  vaginal  and  abdomi- 
nal operation  for  the  removal  of  a  non-gravid  uterus,  I  hesitate 
to  say  much  about  the  details  of  the  procedure ;  but  I  think 
it  extremely  probable  that  the  operation  as  hitherto  practised 
might  be  very  much  simplified  by  drawing  down  the  uterus, 
separating  its  attachments  to  the  vaginal  wall  all  round  as  near 
to  the  uterine  substance  as  possible,  or  exactly  where  the 
peritoneum  is  reflected  off  from  its  walls,  securing  any 
bleeding  vessel  as  it  is  divided  by  pressure-forceps,  not  using 
any  ligatures,  but  leaving  the  forceps  hanging  out  of  the  vagina 


blundell's  views  and  practice  527 

for  two  or  three  days  until  all  danger  of  haemorrhage  has  ceased. 
They  might  be  so  arranged  as  to  serve  the  double  purpose  of 
stopping  bleeding,  and  of  bringing  the  opposite  sides  of  the 
vagina  together  so  as  to  render  peritoneal  sutures  superfluous. 
It  is  very  unlikely  that  if  the  forceps  were  left  untouched  for 
two  or  three  days  any  bleeding  would  take  place ;  and  if  it  did, 
there  would  be  no  more  difficulty  in  applying  a  ligature  than 
in  the  first  instance.  P'urther,  it  appears  to  me  that  sufficient 
attention  has  not  been  paid  in  any  of  these  operations  to  pre- 
liminary compression  of  the  abdominal  aorta  by  tourniquet  as 
a  safeguard  or  preventive  of  bleeding,  or  to  compression  of  the 
aorta  by  the  fingers  of  an  assistant  when  bleeding  occurs  during 
the  progress  of  the  operation.  It  is  also  probable  that  Mr. 
Davey's  plan  of  compressing  the  iliacs  by  a  sound  passed  up  the 
rectum  might  also  occasionally  prove  useful.  I  can  imagine  it 
to  be  quite  possible  in  persons  where  the  abdominal  wall  is  lax, 
either  by  a  modified  tourniquet  or  by  the  hand  of  an  assistant, 
so  to  force  the  parietes  backwards  and  below  the  brim  of  the 
pelvis,  as  to  push  the  uterus  downwards,  keep  the  intestines 
in  the  upper  part  of  the  abdominal  cavity,  and  at  the  same 
time  to  check  the  circulation  in  the  aorta  or  the  iliacs,  and  thus 
render  the  operation  almost  bloodless. 

More  than  fifty  years  ago,  Blundell,  after  long  consideration, 
based  upon  a  series  of  experiments  to  show  the  effect  of  peri- 
toneal section  and  manipulation,  and  fully  aware  of  the  difficul- 
ties and  risks  of  the  operation,  proposed  excision  of  the  cancerous 
uterus.  He  brought  forward  his  views  with  no  very  sanguine 
expectations,  and  simply  advocated  the  extirpation  as  a  last 
resource,  which  might  perchance  restore  a  measure  of  life  to  a 
few  of  the  many  women  who  were  menaced  with  speedy  and 
inevitable  death.  He  carried  out  his  proposition  for  the  first  time 
in  September  1828.  He  did  four  cases,  three  of  which  proved 
fatal — two  within  six  hours  of  the  operation,  one  after  thirty- 
nine  hours — and  one  lived  a  year,  when  on  examination  cancer- 
ous masses  were  found  in  the  pelvis.  All  Blundell's  operations 
were  performed  through  the  vagina.  A  very  interesting  account 
of  them,  and  of  the  thoughts  and  experiments  which  led  him 
to  attempt  them,  may  be  found  in  his  work  on  *  Obstetric 
Medicine,'  published  in  1840,  from  page  752  to  page  784. 

Three  deaths  out    of  four   cases,   and  a  recurrence  of  the 


528  RESULTS   OF   EXCISION    OF   THE    UTERUS 

disease  within  a  year  in  the  only  patient  who  recovered,  will 
account  for  the  fact  that  the  idea  of  extirpation  of  the  cancerous 
uterus  was  not  revived  in  England  until  1878,  when,  in  the 
Hunterian  Lectures  at  the  College  of  Surgeons,  I  made  known 
Freund's  operation  of  excision  through  the  abdominal  wall.  It 
has  not  yet  been  done  in  England  with  any  good  results.  In 
the  two  instances  of  which  I  have  heard,  death  has  followed 
after  a  short  interval.  And  it  cannot  be  said  to  have  proved 
successful  in  Germany  and  Italy  ;  but  the  experience  of  Freund 
himself  and  other  operators  up  to  the  end  of  1880  has  been 
collected,  and  Olshausen  has  commented  on  the  particulars  of 
94  cases.  Of  these  24  survived  the  operation ;  but  in  nearly 
every  case  there  was  a  return  of  the  disease,  and  in  some  of 
them  after  a  very  short  time — an  experience  corresponding 
almost  exactly  with  that  of  Blundell.  Among  the  fatal  cases 
some  died  of  shock,  some  from  bleeding,  and  others  from  septic 
peritonitis.  Six  times  one  of  the  ureters  was  divided.  In  two 
other  cases  the  same  accident  befel  both  ureters,  and  four  of 
the  operations  were  never  completed.  Immediate  consequences 
so  discomfiting,  and  results  so  negative,  could  not  be  accepted 
as  the  ultimatum  of  surgical  science,  and  operators  turned  their 
attention  to  the  mode  of  excision.  Delpech  had  a  long  time 
before,  in  1830,  indicated  a  combined  hypogastric  and  vaginal 
operation,  and  now  it  was  extraction  by  the  vagina,  long  ago 
practised  by  Blundell,  that  came  again  to  be  adopted.  Olshausen 
has  accumulated  the  history  of  44  such  operations,  showing  an 
outcome  of  29  recoveries,  12  deaths,  and  3  incomplete  opera- 
tions. We  have  here  an  advance  of  more  than  40  per  cent,  in 
favour  of  this  procedure,  the  relative  mortality  being  for  the 
abdominal  section  about  75  per  cent. ;  that  for  the  vaginal 
extraction  not  quite  30  per  cent.  It  is  true  that  calculations 
upon  such  small  numbers  are  anything  but  conclusive.  Still 
the  indication  is  manifestly  that  a  step  has  been  made  in  the 
right  direction,  and  it  is  that  which  I  should  myself  follow. 
Porro's  operation,  as  we  have  seen,  was  a  supra-vaginal  amputa- 
tion as  a  substitute  for  the  Csesarean  section ;  and  Bischoff  of 
Basle  in  1879  removed  a  uterus,  the  cancerous  cervix  of  which 
impeded  delivery,  from  a  patient  41  years  of  age,  and  at  the 
thirty-fourth  week  of  pregnancy.  She,  however,  died  eleven 
hours  after,  the  left  ureter  having  been  tied.     It  thus  seems  that 


,         LETTEK    OF    BILLROTH  529 

my  own  case  at  present  is  the  only  one  of  the  kind  followed  by 
recovery  and  a  temporary  restoration  to  health. 

Professor  Billroth  of  Vienna,  in  a  letter  to  me,  dated 
Vienna,  November  18,  1881,  says: — 

'  Your  Porro-Freund  case  has  interested  me  very  much,  as  a 
similar  case  occurred  to  me  three  months  ago.  A  strong 
woman,  about  37  years  of  age,  four  months  pregnant,  had  ex- 
tensive carcinoma  of  the  whole  cervix  and  part  of  the  vagina. 
The  whole  uterus  was  extirpated  by  the  vagina.  Bleeding  was 
considerable,  but  recovery  was  rapid.  Unfortunately  it  was 
necessary  to  cut  away  part  of  the  bladder,  leaving  a  hole  in  the 
bladder,  and  a  large  hole  {RiesenlocK)  in  the  peritoneum.  I 
stopped  up  both  with  plugs  of  iodoform  gauze.  These  were  left 
for  eight  days,  and  were  then  removed.  There  was  no  sepsis, 
but  healing.  The  vesical  fistula  remains  for  future  treatment. 
In  another  case,  similar  except  that  the  uterus  was  not  gravid, 
one  ureter  was  wounded.  The  large  peritoneal  opening  was 
plugged  with  iodoform  gauze,  and  the  patient  recovered.  But 
I  cannot  heal  the  ureter  fistula.  Still  the  disinfecting  power 
of  iodoform  is  by  these  cases  clearly  established.  By  no  other 
means  could  the  decomposition  of  the  wound  secretion  and  of 
the  urine  flowing  through  the  fistula  have  been  prevented,  and 
death  would  have  been  certain. 

6  Unfortunately  my  very  successful  results  of  total  extirpa- 
tion of  the  carcinomatous  uterus  per  vaginam  are  very  disap- 
pointing so  far  as  regards  relapse.  Even  in  the  two  eases  just 
described,  where  I  extirpated  up  to  the  extreme  limits  of 
anatomical  possibility,  there  is  already  recurrence.  Of  what 
use  are  all  our  pains  and  art ! '  ('  Was  nutzt  da  aWunsre  Millie 
und  Kunst ! ') 

The  question  of  the  extirpation  of  the  cancerous  uterus 
has  a  very  different  aspect  during  pregnancy  and  in  the  non- 
gravid  state.  For  a  pregnant  woman  something  must  be  done 
to  save  her  life.  When  not  pregnant  the  question  is  one  of  ex- 
pediency, not  of  necessity,  and  it  seems  probable  that  there 
will  be  very  few  cases  in  which  a  positive  diagnosis  can  be 
made  when  the  disease  has  not  extended  so  far  as  to  put  ex- 
cision beyond  all  reasonable  hope  of  success.  In  the  early  stages 
diagnosis  is  often  doubtful,  and  so  serious  an  operation  would 
not  be  submitted  to  if  recommended.    At  a  later  stage,  when  a 

M  M 


530        TREATMENT  BY  CAUSTICS  AND  CAUTERY 

more  positive  opinion  is  attainable,  and  the  disease  is  ap- 
parently confined  to  the  cervix,  destruction  by  caustics,  or  the 
actual  cautery,  or  cutting  or  scraping  away  of  the  diseased 
parts,  followed  by  the  application  of  the  chloride  of  zinc  or 
some  other  corrosive  agent,  or  amputation  of  the  cervix,  are  all 
methods  of  treatment  which  would  have  to  be  considered  be- 
fore proposing  total  extirpation.  And  although  the  results  of 
these  proceedings  have  not  been  very  satisfactory  so  far  as 
extension  or  recurrence  of  the  disease  is  concerned,  yet  the 
immediate  danger  to  life  is  very  small  compared  with  that 
attending  removal  of  the  whole  uterus.  In  many  cases  great 
relief  is  obtained  for  a  time,  loss  of  blood  and  offensive  dis- 
charges are  stopped,  pain  is  lessened  and  the  general  health 
improved.  I  have  known  two  cases  in  which,  after  removal  of 
the  diseased  cervix  and  the  use  of  the  actual  cautery,  the 
patients  died  about  five  years  later  on  of  some  other  disease, 
no  return  of  that  of  the  uterus  having  been  observed.  But  in 
no  other  case  which  has  been  subjected  to  the  same  treat- 
ment by  me  has  the  relief  lasted  many  months  ;  and  of  course 
it  can  only  be  expected  to  be  at  all  useful  when  the  disease  is 
confined  to  the  lower  segment  of  the  uterus. 

In  cases  where  the  fundus  or  body  is  affected,  if  any  surgi- 
cal measures  are  admissible,  excision  by  the  vagina  would  be 
the  resource  to  which  our  present  knowledge  inclines  us.  And 
if  it  be  done  sufficiently  early,  by  operators  who  have  made 
themselves  masters  of  all  the  details  of  manipulation  by  prac- 
tice on  the  dead  body,  and  by  carefully  studying  the  records  of 
the  cases  hitherto  published,  we  need  not  despair  of  establish- 
ing for  excision  of  the  cancerous  uterus  a  higher  scale  of  suc- 
cess, with  fewer  failures  and  more  recoveries,  and  of  being  able 
to  rescue  from  their  misery  as  large  a  proportion  of  our  patients 
as  any  surgeons  can  claim  to  do  when  they  exercise  their  art 
for  the  removal  of  cancer  from  other  parts  of  the  body. 


LJ 


DATE  DUE                                 | 

n  IMS      FFR  °  n  1QQt* 

JAN  3 

U     |7~3.        IL 

• 

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Printed 

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0037562142 


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W46 
1882 


Wells 
Ovarian  and  uterine  tumours 


R64k/ 


1381 


